Wired UK Illustration by Lee Hasler. Click for Wired UK source.

The UK edition of Wired magazine just ran one of their ‘featurettes’ on this blog and picked their favorite (though, that’s a slightly squint word-choice for potentially deadly accidents) types of projectile accidents. Quote’s from — and a direct link to — the article follow.

Often when I renew my subscription to Wired (the US edition) I get the complimentary tote, or whatever other trinket they’re giving away. This time, however, apparently my renewed subscription coincided with a small feature in the UK edition for this blog! [Perhaps I should start subscriptions to Forbes or Yachting to see if there's content-related good fortune that rubs off from either of those!!]

Below are quotes from the article (the original version of which is just a click away on the article title, below) and some of my added links to related content that aren’t in the online edition of the article. Please do visit the Wired UK site (click on the quoted headline, below) because they have embedded links to other, very interesting related Wired articles.

MRI’s fatal attraction

By Vaughan Bell|06 August 2010

Look out! It’s the dark side of the magnetic force

“It’s like Russian roulette, except that many don’t know that they’re even playing,” says Tobias Gilk, a California-based MRI safety consultant. MRI scanners have electromagnets so powerful that they can dislodge pacemakers, suck in beds from across the room and turn small metal objects into dangerous “ferromagnetic projectiles”. Gilk now collects data and reports of incidents at mrimetaldetector.com/blog.

[Well, maybe not dislodge pacemakers, but certainly disrupt them... sometimes with fatal results.]

Here are six of Wired’s favourite MRI metal menaces.

Floor polisher
This is so common that the internet has whole galleries of trapped cleaning machines. Floor polishers end up stuck in scanners when cleaners stroll into MRI facilities out of hours and only realise they’re in trouble when their equipment starts to gravitate towards the magnet.

[We could establish a very long gallery of floor polisher accident photos. In fact, in the 'Flying Objects' image collection of my friend Moriel Ness Aiver on his website, SimplyPhysics.com, there are quite a number of them to see! And while they don't show you the actual accident, here's a link to a Seattle news story on a floor-polisher meets MRI accident that occurred there.]

Metal gurney
A patient and a metal gurney were both lifted off the ground and pulled towards the magnet as they were accidentally wheeled into the MRI room. The scanner had to be shut down in order to free the bed, and the unlucky patient suffered from foot, ankle and leg fractures.

[Here's a link to the FDA accident report for this specific accident (the news account having been linked above). And here's a link to a popular image showing an ICU bed magnetically adhered to the face of an MRI scanner.]

Pistol
An MRI machine disarmed an off-duty US police officer. She forgot she was carrying her Glock pistol as she accompanied her mother, who was being scanned. The gun was pulled by the magnetic force, jamming her hand between the pistol and the machine and trapping the officer.

[Here's a link to my summary of the news story from that specific incident. There is also a peer-reviewed journal piece on a different, but similar, incident in which the handgun actually fired, despite the presence of two engaged safeties.]

Flat-screen
A member of the public who was inside the scanner solely for research purposes got badly injured when hospital staff walked a flat-screen monitor through the room. The magnetic field tried to put the screen and the participant in the same place; the next stop was casualty.

[Here's the link to the FDA accident report PDF for this one, too.]

Scissors
An MRI technician ended up with a pair of scissors embedded in his forehead as he prepared a patient. Someone entered the scanner room with the scissors in their pocket — they were pulled out by the magnet and collided arrowstyle with the technician’s head.

[There have been multiple accidents involving flying scissors in the MRI room. This one is among the most severe.]

Wheelchair
A wheelchair brought into the danger area shot across the room and pinned a radiographer to the scanner. The staff member was unharmed but a patient waiting for her scan was so frightened she fell off the bed and broke her leg.

[As with floor polishers, there have been many, many incidents of not-safe-for-MRI wheelchairs being brought to the MRI room. You can see a couple of these, as well as a sampling of other projectile objects here.]

Wired UK, September 2010

I am very flattered that the editorial staff at Wired UK included information on our humble little blog in their September, 2010 issue. I hope that this sort of attention raising opportunity is not lost on the audiences in the US and elsewhere.

Click here for Tobias’ Twitter Profile

It took a while, but slowly I realized that tellin‘ and getting in trouble were two, very different things. This is a lesson that we in the MRI community would do well to learn regarding accidents.

MRI accidents – in which materials, devices and implants which have no business in the MRI scanner room – occur all the time. Mostly, these are caught in advance, before anyone is injured or anything is damaged. Fairly frequently though, the MRI’s magnet ‘finds’ cell phones, money clips, pocket-knives, unsafe wheelchairs, etc…. And fairly frequently large ‘black hole’ artifacts on initial scans expose ferromagnetic devices or implants that the patient disavowed in their clinical pre-screen. (A veritable photo album of projectile accidents is available in one of my recent posts, which you can access here.)

Because these sorts of events are often rationalized to be statistical inevitabilities, brushed-off as events that occur at all MR facilities (and, therefore, are certainly not news to anyone), little – if anything – changes as a result.

Now, because these accidents and ‘near-events’ are typically accepted as unavoidable, they are very, very rarely reported outside of mandatory reporting structures, such as the State of Pennsylvania’s Patient Safety Authority. And even within mandatory structures such as Pennsylvania’s, many projectile events never get a 2nd thought, much less an event report. The upshot is that others, who might have learned from these surrogate mistakes, are more likely to have the same mishap because neither the nature or the frequency are shared with the community at large.

‘But wait, Mr. MRI-safety man. There is a national MRI accident database kept by the FDA and reporting to the FDA’s database is mandatory.’

Yes, there is a FDA accident database. And yes, technically, reporting is mandatory. The accident reporting system is called MDR (Medical Device Reporting) and the data is published in the FDA’s MAUDE database (which anyone with an internet connection can access and search). The three criteria for mandatory accident reporting are:

• Death (pretty unequivocal)
• Serious Injury
• Unreasonable Risk of Death or Serious Injury

What constitutes serious injury? Well, if you’re a healthcare provider, you get to make that call as there is no standard that the FDA uses. Want to call a traumatic amputation a ‘slightly-less-than-serious’ injury? OK. Want to not report it because you’ve determined that it isn’t a ‘serious’ injury? The FDA says that’s OK, too.

We don’t even need to touch on unreasonable risk unless, of course, we’re talking about the risk of death, but then we open the question of what makes something ‘unreasonable.’ I suspect that the FDA leaves that determination up to the individual as well.

So given the two indisputable truths above (1) MRI accidents are reported only a mere fraction of the time and (2) even the reporting requirements have loopholes that you could drive a truck through, what is the point of this article?

Ignore precedent. Ignore lawyerly readings of the reporting language. Report every MRI accident and near-event that occurs.

‘What? OK, Mr. MRI-safety man, you’ve really gone off the deep end on this one!’

Hear me out. Remember my intro to this article… the difference between being ‘told on’ and getting in trouble? That wasn’t just a cute story to draw you into an unrelated article, it’s an analogy for what happens when MRI providers report accidents and near misses to the FDA.

First, accident reports go through your MRI manufacturer and do not need to go directly from you to the FDA (except in cases of death). Second, accident data is anonymized. There is nothing that needs to identify you, your facility, your location, anything other than the scanner involved in the accident.

But the most important reason to have your MRI manufacturer report these events is that, by sharing the information about the types and frequencies of accidents, our entire industry will be able to better respond, as a whole, to the [wink, wink] events that are too often taken for granted.

With a more accurate picture of what goes wrong and, even more importantly, what steps we can all take to make things right, we can each do our small part in helping to improve the safety and effectiveness of the entire MRI industry.

There is no 7-foot tall troll waiting for you at the other end of your accident report to the FDA. There is no enhanced regulatory scrutiny that follows. Heck, nobody external to your organization will even ask you if you’ve done anything to increase your chances of catching that same mistake again. In short, there is no real downside, though the information you provide may ultimately help another MR provider prevent a costly or dangerous accident.

Ferromagnetic detection doesn’t catch anything that existing screening protocols aren’t meant to catch.

That inflection makes a world of difference, as you’ll see in just a moment…

We’ve been screening for ferromagnetic materials as long as MRI has existed, but our historic technique of simply asking if someone has magnetic materials has not proven very effective. There are many accounts of magnet damage, injuries, and fatalities resulting from a failure to identify ferromagnetic materials before they were brought into the MRI room. And despite a universal familiarity with the risks of ferromagnetic materials, we as an industry seem unable to prevent them from recurring by using only these ‘old school’ screening protocols.

There was a policy in place to screen for ferromagnetic materials at this New York hospital in 2001:

And they had a policy to screen for ferromagnetic materials at this Seattle hospital in 2005:

They had a policy to screen for ferromagnetic materials at this hospital:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And here:

And lots, and lots of places that you can see here:

Honestly, I could drown you in pictures and accounts of ferromagnetic materials in the MRI suite. Suffice it to say that the accounts above are only the tip of the iceberg.

One of the most ironic (in light of what you’ve seen above) arguments against the need for ferromagnetic detection is that it isn’t foolproof.

Foolproof!?!? If that’s the standard, how can we reconcile the results of our conventional screening practices against this expectation of perfection? Clearly, we’re a very, very long way from that goal.

Instead of willfully disbelieving everything shown above… Instead of insisting on the infallibility of patient and visitor compliance with screening instructions, or the unblinking door-watching vigilance of the Technologists, or the guaranteed long-term effectiveness of MRI safety training for housekeeping, transport, engineering, security, anesthesia, ICU and respiratory staff, why can’t we accept that each of these protections, as valuable as they are, are imperfect, and that if maximum safety is our goal, we need to augment these long-standing – and incomplete – strategies with something new.

I freely state that ferromagnetic detection is not perfect. Under certain circumstances, it can miss things that we may want to find. It does, however, provide us with an entirely new feedback mechanism that helps us to more effectively monitor, train, screen, and protect people in the MRI environment. Imperfect though it is, it is remarkably effective at helping to improve the safety of everyone inside the MRI suite.

PS: I would like to thank the following people who have helped me by providing some of the images you’ve seen above, Moriel Ness Aiver, Raj Sangoi, and Keith Del Guercio.

No, not me, the author, but the figurative ‘me‘, this blog…

I don’t know if you’ve ever used them, but all of the major internet search engines have tools that you can use to find images that match your search criteria. Every so often there’s a new paparazzi picture of some starlet in mid-wardrobe-malfunction or a politician with a facial expression that looks like they just smelled something awful that become the ‘it’ picture of the day.

Well, based on the number of hits our blog has been getting recently, and the image search tools that many of these hits are coming from, apparently we have a lesser ‘it’ picture, and it has nothing to do with politics or racy nudity…

It’s a picture of an ICU bed stuck to the face of an MRI.

Pictures of things stuck to magnets often generate wide-eyed looks, even laughter. After all, the juxtaposition can be pretty silly. But each of these pictures is only possible because of horrible mishaps that can each result in serious injury, or even fatality.

We encourage people to find and view these pictures, not to have a larger number of viewers snicker at them. We put them up to help deflate the ‘that could never happen here’ mythology that is dangerous. If you can see magnets, floor polishers, oxygen cylinders, wheelchairs or, as above, ICU beds that look like ones in use at the hospital or imaging center, then maybe the internal monologue becomes something more like, ‘what would have to happen here for us to have a similar accident?’

Most importantly, we hope that all of these efforts work to motivate Technologists, Radiographers, Imaging Managers, Radiologists, Risk-Managers and Compliance Officers to imagine which steps they could take at their locations to reduce the likelihood of these sorts of accidents.

There are many steps that can be taken to help improve the effectiveness of pre-screening for magnet hazards. One of the most obvious is also one of the easiest, the use of ferromagnetic detectors.

We encourage you to view and share the information contained on these pages and we hope that each of these resources, even the racy pictures of MRI missile accidents, help shape improvements to MRI safety at your facilities.

After all, I’m lot more than just a pretty face…

As everyone who’s spent more than an hour or two around an MRI knows, these super high-strength magnets have a reputation for ‘sucking-in’ ferromagnetic materials that are so prevalent in wheelchairs, gurneys, gas cylinders, fire extinguisher, and carts.

In the last few years, there’s been a spate of floor polishers that have found their way into MRI scanners across the country…

But while there’s a nearly universal urge to snicker at these images, it is important to realize two crucial things about each and every projectile accident.

First: Each and every MRI missile effect accident is theoretically 100% avoidable. By prospectively identifying the ferromagnetic nature of materials before they’re brought into the MRI suite, none of these need to happen. By following best practices including the ACR’s Guidance Document, or the Joint Commission Sentinel Event Alert, and deploying ferromagnetic detection screening of all people and materials approaching the MRI scanner, it is possible to prevent projectile accidents.

Second: Each and every ferromagnetic projectile incident has all the ingredients for injury. While there is only one official account of a projectile-related fatality, there are many, many reports of injury, a good number of which have been severe. And given the abysmal rates of MRI accident reporting, it’s entirely believable that other anecdotal accounts of MRI-projectile fatalities are more fact than fiction.

These projectile accidents are more commonplace, and more dangerous than many are aware. So what can you can do to avoid becoming a part of the MRI missile accident scrapbook? Start by reviewing all of your MRI safety protocols, and consider deploying ferromagnetic detection screening for each and every MRI.

PS: If you’d like to find more pictures, and even a video or two, on MRI accidents, I encourage you to check out www.SimplyPhysics.com/flying_objects.html