Lessons Learned from MRI Safety Events

Although MRI is a relatively safe imaging modality as it does not require ionizing radiation, there are many unique aspects or features that make it challenging for patient safety. The constant strong magnetic field in the MRI suite is the basis of projectile incidents. There are time-varying gradient magnetic fields and radiofrequency magnetic fields that are utilized in creating the MRI images that can interact with certain implanted or indwelling devices and result in patient harm if not correctly recognized and accounted for. These may also underlie other potential adverse events in MRI, including hearing damage and burns. Although multiple safety practices are in place to prevent injury, collective human errors can “align” to allow dangerous incidents to occur. This report discusses MRI safety incidents that have occurred involving inadequate communication, medication issues, and projectiles, and includes the lessons learned and improved practices that have been instituted to help improve safety in the MRI environment. © 2015, Springer Science+Business Media New York.