Hundreds of patients with metallic implants narrowly avoided death or serious injury after being wrongly referred for MRI scans, an investigation revealed yesterday.
The powerful magnets used in the machines can displace and damage metallic items such as pacemakers, ear implants and aneurysm clips.
Doctors should question patients and check medical records before requesting a scan because of the risk of injury. But hospitals in England recorded 315 near-misses from April 2020 to March 2022 involving patients sent for an MRI.
An MRI scan at Mid Yorkshire Hospitals Trust was ditched after staff confirmed the skin over the patient’s pacemaker had begun heating up. Another patient – at Wrightington, Wigan and Leigh Trust – told staff about a metal plug implanted in their nose only after the scan had begun. Many of the incidents involved forms being filled out incorrectly on behalf of elderly and disoriented patients.
At East Kent Hospitals University Trust, a patient described as ‘not compos mentis’ was given the all-clear by a care home nurse and again by a clinician for MRI – only for staff to realise at the last moment that metal clips were implanted in their chest. Information about the incidents was obtained using freedom of information requests.
Helen Hughes of Patient Safety Learning, said: "It is vital that near-misses are regularly reported, their causes understood, and that this learning is acted on to prevent future avoidable harm."
Source: MailOnline, 15 October 2022
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