From the September 2012 issue of HealthCare Business News magazine


“MRI accidents are not common, and there are few injuries, which is a good thing. But these accidents and incidents are unnecessary and entirely avoidable. If they would be more common, then at least someone would step in and say this is unacceptable,” he says.

The increasing number of MRI procedures should also be taken into consideration. “In the U.S., we’re doing 30 million MRI exams on an annual basis. If your denominator is 30 million it doesn’t take a big numerator to wind up producing a lot of injuries,” says Gilk. In addition, magnet strength, gradient power and radio frequency transmissions in the machines have increased as a result of improvements in MRI technology, but those improvements could make the rare injury more serious.



According to data from MedWatch, the FDA safety information and adverse event reporting program, the number of complaints about MRI burns, thermal discomfort or direct thermal injury have skyrocketed since 1992. This was the same year the first sequences that increased power deposition in the machines were approved.

Gilk and Kanal reviewed two years’ worth of MRI accident data from the FDA and found that the majority of MRI accident fit into three categories: Burns, projectiles and hearing damage.

“I was surprised that these three accident types comprised more than 90 percent of all reported accidents and that these are almost universally preventable through existing best practice standards,” says Gilk.

Kanal, who was the chair of the ACR MR Safety Committee from 2001 through 2012, has performed dozens of MR site safety reviews. “Usually I am called in after the horse is already out of the barn”, he says. “Once the incident has already transpired, the powers that be call me in to review their MR safety and suggest guidance for future improvements. Only a few have the foresight to recognize how much more practical— and in the long run far less expensive—it is to call me in before a serious adverse event transpires, when it can be anticipated, avoided, and designed or defended against.”

Examples of recent accidents include: an infant receiving a burn so severe that she ultimately lost an arm; scissors flying out of a responding assistant’s pocket and getting embedded in the technologist’s head; and burns inside a patient’s brain that resulted in a comatose state.

September 2012 Magazine

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