[An investigative report concerning safety and management in the magnetic resonance environment: there are more accidents than expected].

Abstract

Using a questionnaire, we surveyed 2,500 facilities in Japan to clarify medical accidents concerning the magnetic resonance device and its environment. Data derived from 1,319 valid responses (52.8%), allowed us to analyze the situation of (or the reason for) the occurrence of the accidents and their environmental factors. Five hundred and nine facilities (39% of all facilities) had the experience of magnetically induced displacement of the large ferromagnetic material. Intravenous (I.V.) drip stands were involved the largest number of them: 31% (228 cases). Oxygen bottles had the second largest number of incidents: 20%. There were also many incidents involving various materials brought in by non-medical staff (e.g. stepladder for construction). About 20% of the accidents occurred outside of working hours. Patients in 12% of the facilities (154 facilities) experienced burns. In 39 of the cases, burns were received to the inside of the thighs. In 38 of the cases, patients received burns from an electrical cable touching the skin. There were also frequent incidents of burning regarding the boa. We received reports of burns and pain from the halo vest even though it's required to be worn for MR safety. Regarding incidents of contraindications, 280 patients with pacemakers were brought into the magnetic resonance (MR) inspection room. Twelve percent of the facilities experienced natural quench. Lack of training for the staff who introduce and operate high magnetic field devices are considered involving frequently occurring accidents of attractions and burns at hospitals with over 500 beds caused by carrying in materials.