Technology meets moral imperative

January 28, 2004

By Greg Freiherr, Editor, gfreiherr@cmp.comIt's been more than two years since the tragic accident that caused the death of six-year-old Michael Colombini, struck by an oxygen

By Greg Freiherr, Editor, gfreiherr@cmp.com

It's been more than two years since the tragic accident that caused the death of six-year-old Michael Colombini, struck by an oxygen tank turned missile by the magnetic field of an MR scanner. In the weeks and months following this accident, the MR community debated and an expert panel drafted guidelines designed to reduce the chance of such an accident happening again. But, in reality, there is no surefire way to stop accidents. Not then. Not now. In the near future, however, a metal detector specific to ferromagnetic objects will be available. And that could be huge.

For the first time, the MR community will be armed with technology specific to the task of protecting patients. Until the release of FerroGuard, which was developed by ETS-Lindgren and is now undergoing tests at clinical sites, staff at MR facilities must continue to rely on their wits to prevent accidents. What makes this so hard is that accidents tend to occur not due to the fault of MR staff but to the fault of others who do not comprehend the importance of keeping ferromagnetic objects away from MR scanners.

An article in the July 2001 issue of the American Journal of Roentgenology cites incidents of gas tanks, a defibrillator, a wheelchair, a respirator, ankle weights, an IV pole, a toolbox, sandbags containing metal filings, a vacuum cleaner, and mop buckets being pulled into MR equipment at imaging facilities across the U.S. In one incident, a patient was hit in the face by a flying tank, sustaining facial fractures. The university paid $100,000 to the patient for negligence and another $32,000 to repair the magnet, losing a week of exams while the scanner was repaired.

The financial cost of accidents is the business justification for preventing them. Another is the moral imperative on all healthcare providers to first do no harm. A device designed to detect the presence of metal objects before they become projectiles will help, but it is not the whole answer. Staff will have to turn on this detector. They will have to make sure the device is tuned to the proper sensitivity and that it is, in fact, working. They will have to listen for its alarm, and they will have to be ready to act, if the alarm sounds.

These may seem simple requirements, but they are, nonetheless, vulnerable to human frailties. Accidents can be prevented only through vigilance and commitment by the people charged with the safety of patients. But soon, at least, these people will have help.