We have heard a lot in the news today about imaging but this one is different, as MRIs use magnetic energy and with a metal gurney not approved for use here, a mistake was made and the magnets went to work and sucked the patient in, damaging her leg and sending her to the ER room. I certainly hope this MRI is “on the house” after this occurred. In addition, the hospital was also fined.
Once more, a checklist comes into play here with making sure all safety issues are in compliance and the hospital installed a camera for monitoring. With diagnostic imaging, I think we need to take time and not be rushed in order to meet production goals that we are commonly seeing at hospitals these days relative to the amount of revenue needed to cycle through to meet the numbers where they are using business intelligence software to calculate the numbers needed. Some hospitals are even telling doctors these days that they are not meeting their admitting goals too, in other words get more patients in here so we can keep the doors open sometimes.
One more item as a patient we might keep in the back of our heads and maybe be a bit of a pain, but ask before the procedure if you are riding on an “approved gurney”. This is somewhat a unique situation, granted, but it could occur anywhere and this occurred at a highly rated care hospital in Orange County, CA. BD
Hoag Hospital has been fined $50,000 by the state Department of Public Health after an MRI patient on a metal gurney was magnetically pulled into the imaging machine, the hospital said Friday.
In a memo to staff, Dr. Richard Afable, chief executive officer of Hoag Memorial Hospital Presbyterian, described the scenario and policy changes to prevent future incidents. He was in Los Angeles on Friday and could not be reached for comment.
Afable said that last January a woman was taken into an MRI room on a metal gurney that was not compatible with the machine. The powerful magnet in the MRI pulled the gurney into the machine and the patient's leg was trapped for about three minutes. She was taken to the emergency room and spent three days in the hospital for treatment of fractures in her lower leg and foot.
The hospital has adopted new procedures including a checklist that must be done before entering the MRI room and installation of a camera for monitoring.
Hoag fined in MRI accident | mri, hospital, hoag - Life - The Orange County Register
The accident also was reported to the FDA (available through their MAUDE database).
ReplyDeleteHere's a blog entry that correlates the two (the FDA report and the newspaper story).
Also, do we really want to expect patients to be able to tell if the gurney they're on is ferromagnetic or not? Hell, most of the time the transport staff may not know, themselves! These MRI providers should be using ferromagnetic detectors, like the ACR, Veterans Admin, and JCAHO have all advised!
D'oh! Homer Simpson moment. Forgot the link to the blog article...
ReplyDeletehttp://mrimetaldetector.com/blog/2010/01/gurney-crashes-mri-patient-injured-hospital-fined-50k/
Thanks for adding the links here, I took a look and watched the video on the blog site, you are right, sensors should be in place for this
ReplyDeleteI did a post a while back too on an MRI exploding when it was being moved too.
There is a medical physicist, from UAB, I believe, who published a paper within the last years or so about MRI explosions. Probably in response to the most severe one (that I know of) which happened at a UAB facility 3 years ago.
ReplyDeleteGlad you liked the referenced link. That site has lots of information on ferromagnetic (only) detection systems that likely could have alarmed on the bed _before_ it took the patient for the ride that broke her ankle.
MRI stand for Magnetic Resonance Imaging which is a technology that uses magnetic signals to show the different tissues inside the body allowing a digital image of inside the human body to be created. MRI's are primarily used to study nerves, muscles, ligaments, bones, and numerous other tissues in the body, primarily soft tissues.
ReplyDeleteHope all parties are safe!
ReplyDeleteThanks for sharing this article! It's very informative and hopefully will prevent more accidents in the future. Awareness is key!
ReplyDelete