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Sentinel event alert issued on MRI safety

Quality Improvement Monitor, February 22, 2008

The Joint Commission last week issued a sentinel event alert, calling on ambulatory care centers to take special care to prevent accidents and injuries that can occur during magnetic resonance imaging (MRI) scans.

The Food and Drug Administration has received nearly 400 reports of MRI-related accidents over the past decade, according to a Joint Commission press release. More than 70% of accidents were burns and 10% of injuries occurred when metal objects such as ink pens, cleaning equipment, and oxygen canisters have become "missiles" when pulled into the magnetic field of the scanner.

"MRI technology represents an important advance in diagnostic medicine, but special care must be taken to protect patients," Mark R. Chassin, MD, MPP, MPH, president of The Joint Commission said in a press release. "The increasing use of MRI scans as a diagnostic tool, coupled with stronger MRI technology, suggests that the risk of accident and injury may increase. This alert offers health care organizations specific steps that can be taken to keep patients safe."

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