A June New Jersey Department of Health patient safety alert regarding sandbags containing metal shot was published in a National Patient Safety List Serve. The case described a cardiac catheterization patient that was sent for an emergency MRI post procedure. As is frequently the case, the patient had a sandbag placed over the catheterization site and upon entering the MRI room the sandbag was pulled off of the puncture site and adhered to the wall of the MRI. Fortunately, the patient was not harmed. One would presume that all purchased “sandbags” are filled with sand. What we found was very surprising.
Based on the event in New Jersey, St. Luke’s Hospital and Health Network’s Radiology Department thought it would be prudent to test our sandbags for the presence of metal. Using a handheld 1.0 tesla magnet, the Director of MRI to date has tested 122 “sandbags” and found 19 bags that were magnetic. Sandbags were found to contain sand, or sand and metal shot, or metal shot. The sandbags that contained sand and tested safe have been labeled MRI SAFE. Unsafe sandbags have been discarded. In the future, all newly purchased sandbags will be sent to the MRI department for testing prior to patient use.
PA-PSRS is aware of the original advisory in the New Jersey Department of Health and Senior Services Patient Safety Initiative’s Alert of May 2006: MRIs and Sandbags Filled with Metal Shot. We are pleased with the contribution of our colleagues in New Jersey to the patient safety effort and with this evidence that we can apparently all benefit from the efforts of each state’s reporting, analysis, and dissemination of lessons learned.
We also commend St. Luke's Hospital and Health Network for their proactive initiative to recognize and remove a hazard before any mishaps occurred in their facility. While PA-PSRS has found only one report of a similar event in the database of over 370,000 reports, the St. Luke’s Hospital and Health Network report of 19 hazardous sandbags in their facility alone indicates that this problem is potentially more serious. In response to this letter, we have searched PA-PSRS and identified information that reinforces the New Jersey experience (see page 11 of this Advisory). Our thanks to New Jersey for its initial report of the problem, to St. Luke's Hospital and Health Network for doing the survey that indicated that it was not a rare opportunity for harm, and to Mr. Norder and Ms. York for sharing the information.