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Brazilian lawyer dies after gun goes off in MR suite

por John R. Fischer, Senior Reporter | February 15, 2023
MRI Risk Management
A Brazilian lawyer died from a gunshot wound he sustained after an MR scanner caused his firearm to go off.
A Brazilian lawyer has died from injuries sustained from being shot by his own gun inside an MR suite.

Leandro Mathias de Novaes, 40, was accompanying his mother for an MR scan on January 18 at Laboratorio Cura, a diagnostic center in São Paulo, and was asked to remove all metal from his body before entering, according to CNN Brazil.

Novaes signed a form acknowledging that all metal must be absent but did not disclose that he was carrying a concealed weapon.
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When the machine was turned on, the magnetic force pulled the gun from his waistband, causing it to shoot him in the stomach. He was rushed to the São Luiz Morumbi Hospital, where he died Feb. 6.

A preventable tragedy
Researchers at the Pennsylvania Patient Safety Authority reported in 2019 that a quarter of MR adverse events are the result of unintended internal and external ferromagnetic objects brought into the scanning room. These can include firearms, metal implants, and more.

A similar incident occurred in India in 2018 when a 32-year-old man was sucked into an MR suite with a metal oxygen tank. His hand was stuck, and the oxygen tank, which was running, opened and filled his lungs with air. He later died from his injuries.

If undergoing a scan, metal implants or even wearing a COVID-19 mask with metal components risks leaving burn marks on patients.

Safety strategies
One common solution is to adopt ferromagnetic (FM) detectors, which can detect and alert providers to the presence of ferromagnetic materials on a patient or staff member. Experts encourage providers to have at least two for the entryway and prescreening process.

A dedicated MR technologist should also be present, and staff members should be properly trained to know the limitations of safety technologies, as well as what other actions they can take to further prevent adverse events as in Novaes’ case.

Laboratorio Cura told news outlet Jam Press that it followed all protocols to prevent any accidents. “Both the patient and his companion were properly instructed regarding the procedures for accessing the examination room and warned about the removal of any and all metallic objects. The firearm was not mentioned by the companion, who entered the examination room with the object by his decision.”

Police said the gun was registered and that Novaes, a gun advocate, was licensed to carry it.

Tobias Gilk

Besides the Technologist, What *Systems* Failed, First?

February 16, 2023 11:43

Did the site's policies permit visitors to the MRI scanner room?
Did the site's policies allow visitors back towards the MRI scanner room in their street clothes?
Were the technologists empowered to challenge patients / visitors about compliance?
I understand Brazil has a law requiring metal / ferromagnetic detection for MRI, did this site have it?
Are there licensure requirements or accreditation standards that promise to assure safety? Did they fall down on the job?
Who was the supervising physician for this site, and how involve were they in safety practices?
Who was the manager for this site, and how involve were they in safety practices?

If you're watching a soccer match and you see your favorite team scored against, that ball didn't only get past the goalie... it got past the other 10 field players, first. Yes, in this metaphor the technologist is the 'goalie,' but have we identified who the 'field players' were, and what their responsibilities were to best practices and safe care?

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