Medical Accidents Related to Ferromagnetic Objects Brought into the MRI Room: Analysis of the National Multicenter Database by Orthopedic Surgeons

Abstract

Introduction: Magnetic resonance imaging (MRI) is widely used in orthopedics, but orthopedic surgeons, including spine surgeons, do not have detailed knowledge of MRI-related accidents. We, as orthopedic surgeons, investigated the details of medical accidents related to ferromagnetic objects brought into the MRI room using a national multicenter database. Methods: We conducted an exploratory analysis of accidents involving MRI ferromagnets based on the Japanese database of adverse medical occurrences. From a total of 104,659 accident reports over nine years, 172 involving the presence of ferromagnetic objects in the MRI room were extracted and analyzed. Results: The accident reports frequently involved children and the elderly. Nurses filed the highest number of reports (44.8%) by occupation, which was more than twice as many as physicians (19.8%). The most common ferromagnetic devices brought into the MRI rooms were pacemakers (n = 22). There were also large magnetic objects such as oxygen cylinders (n = 12) and IV stands (n = 7). In the field of orthopedics, ankle weights (n = 4), pedometers (n = 3), and artificial limbs (n = 2) were brought in. “Failure to check” was the most common cause of accidents (69%). Actual harm to patients occurred in 9% of cases, with no fatalities. Conclusions: Manuals and checklists should be developed and continuous education provided to prevent accidents involving magnetic objects brought into the MR scanner room. As orthopedic surgeons, including spine surgeons, we should be cautious with emergency, geriatric, and pediatric patients because their information and medical history may not be accurate. We should not overlook equipment commonly found in orthopedic practice such as ankle weights and pedometers.

Keywords

• mri
• patient safety
• ferromagnetic objects
• reporting system