Pennsylvania Patient Safety Advisory
PA PSRS Patient Saf Advis 2004 Mar;1(1):3.

MRI Hidden Risks

Internal Medicine and Subspecialties; Radiology
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​​MRI Hidden Risks

The PA-PSRS database includes incidents in which an MRI was ordered for a patient who had a cardiac pacemaker. Fortunately, the procedures were cancelled in both cases. Patient injury might have resulted if these patients had received MRI’s.

The healthcare community is most likely aware of MRI-associated patient injuries/death involving ferrous gas cylinders as projectiles.1,2 Also nationwide, other ferromagnetic objects have been involved in projectile incidents when near MRI’s, such as tools, scissors, IV poles, mop buckets, floor buffers, laundry carts.3

What may be less known are the risks associated with items implanted or imbedded within the patient. Studies of implants and prostheses have been conducted associated with MRI’s. Some implants can be adversely affected by the MRI’s electromagnetic fields: for example, cochlear implants, internal or external cardiac pacemakers, implantable infusion pumps, cerebral aneurysm clips. Devices that contain a magnet that might move or become demagnetized, such as dental implants or prostheses with magnetic components may also be adversely affected by the MRI. In addition, metal fragments or shrapnel might be twisted or dis-lodged during the procedure, resulting in patient injury. Persons with tattoos may experience skin irritation as a result of an MRI.4,5,6

Many resources are available that can be utilized to develop strategies to reduce the risk of injury or death related to implanted/imbedded objects and the MRI procedure. Such re-sources include, but are not limited, to the following.

  • American College of Radiology http://www.acr.org
  • Shellock F, Sawyer-Glover A. The magnetic resonance environment and implants, devices and materials. In: Shellock F, editor. Magnetic resonance procedures: health effects and safety. Boca Raton, FL: CRC Press; 2001
  • ECRI. Safety concerns in the MR Environment. Healthcare Risk Control. Volume 4 Radiology 5; September 2002
  • Institute of Magnetic Resonance Safety, Education, and Research http://mrisafety.com
  • Gosbee J, DeRosier J. MR hazard summary: August 2001 update. In: VA National Center for Patient Safety; 2001

References

  1. Archibold RC. Hospital details failures leading to MRI fatality. The New York Times 2001 August 22; B1 
  2. Patient death illustrates the importance of adhering to safety precautions in magnetic resonance environments. ECRI. 2001 http://www.ecri.org.
  3. Carr MW and Grey, ML. Magnetic resonance imaging. American Journal of Nursing. December 2002: 29.
  4. Shellock FG, editor. Pocket Guide to MR procedures and metallic objects: update 2001. Philadelphia: Lippincott Williams & Wilkins; 2001.
  5. Shellock FG, Editor. Reference manual for magnetic resonance safety.  2002 ed. Salt Lake City (UT): Amirsys; 2001.
  6. Kreidstein ML, et al. Mri interaction with tattoo pigments: case report, pathophysiology, and management. Plastic Reconstructive Surgery 1997; 99(6): 1717-20. 
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