Magnetic resonance imaging incidents are severely underreported: a finding in a multicentre interview survey

Abstract

Objectives The purpose of this study was to develop a procedure to investigate the occurrence, character and causes of magnetic resonance (MR) imaging incidents. Methods A semi-structured questionnaire was developed containing details such as safety zones, examination complexity, staff MR knowledge, staff categories, and implementation of EU directive 2013/35. We focused on formally reported incidents that had occurred during 2014–2019, and unreported incidents during one year. Thirteen clinical MR units were visited, and the managing radiographer was interviewed. Open questions were analysed using conventionally adopted content analysis. Results Thirty-seven written reports for 5 years and an additional 12 oral reports for 1 year were analysed. Only 38% of the incidents were reported formally. Some of these incidents were catastrophic. Negative correlations were observed between the number of annual incidents (per scanner) and staff MR knowledge (Spearman’s rho − 0.41, p < 0.05) as well as the number of MR physicists per scanner (− 0.48, p < 0.05). It was notable that only half of the sites had implemented the EU directive. Quotes like ‘Burns are to be expected in MR’ and not even knowing the name of the incident reporting system suggested an inadequate safety culture. Finally, there was a desire among staff for MR safety education. Conclusions MR-related incidents were greatly underreported, and some incidents could have had catastrophic outcomes. There is a great desire among radiographers to enhance the safety culture, but to achieve this, much more accessible education is required, as well as focused involvement of the management of the operations. Key Points • Only one in three magnetic resonance–related incidents were reported. • Several magnetic resonance incidents could have led to catastrophic consequences. • Much increased knowledge about magnetic resonance safety is needed by radiologists and radiographers.

On the mechanism of painful burn sensation in tattoos on magnetic resonance imaging (MRI). Magnetic substances in tattoo inks used for permanent makeup (PMU) identified: Magnetite, goethite, and hematite

“…The immediate onset and end of the MRI burn sensation in hitherto tolerated and noninflamed tattoos, geared by switch on-and-off of the scanner, excludes a cell-mediated response from some preexisting lymphocytic infiltrate and its mediators. 29 Our observation that iron oxide-based ink stock products commonly are magnetic contrasts no indication that every person tattooed with magnetic ink will risk MRI burn sensation. Present clinical evidence indicates only 1-2% of tattooed patients react in their tattoo on MRI.…”

“…Tattoos are long lasting and MRI complications may occur with decades of delay as already noted in the literature. The problem of MRI burn sensation in tattoos is according to a Swedish study from MRI units heavily underreported 29 …”

Problems With Magnetic Resonance Imaging-Conditional Anesthesia Machine During Routine Imaging: A Near-Miss Case Report

“…Fatal accidents with flying equipment have been reported in the past, with the most common cause being projectile cylinders. 2,3,6 In one such case, the accidental introduction of a ferromagnetic cylinder tank into the MRI suite caused a massive collision with the patient, resulting in a facial fracture and $100,000 in reparations. 3 In another case, the projectile collision of a cylinder tank caused $50,000 in damage to the MRI magnet and loss of 1-week imaging time.…”

Dual-energy index variation when evaluating the potential ferromagnetism of ex vivo bullets

“…A recent investigation found that ferromagnetic MRI-related incidents are underreported and that there is a definite desire among radiology staff to broaden and advance the knowledge base and culture regarding the safety aspects of ferromagnetic materials related to MRI investigations. 6 A recent study found that only highly ferromagnetic bullets can potentially shift in vivo position within MRI magnetic fields and that most bullets are non-ferromagnetic. 5 It was concluded that bullet migration within the static magnetic field is minimal and related to the shape and orientation of the bullet.…”