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October 16, 2007
9:00 AM - 11:00 AM
Room Hall D, Area G,
Be Aware Anesthesiologists: MRI Incidents and Injuries Leading to Liability and Litigation
Lauren K. Hoke, B.S., Thomas A. Taghon, D.O., Kristin L. Gorman, B.S., Michael Shackleford, D.O., Yvon F. Bryan, M.D.
Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

Anesthesiologists may not be aware of certain hidden risks involved in providing care to patients in MRI suites. Revised safety guidelines and updated yearly manuals highlight risks to patients and health care personnel in the magnet room (1,2). Despite these publications, near misses and accidents still occur alongside conflicting reports regarding frequency (3). We sought to determine the number and types of reported injuries occurring in MRI suites.

Methods: An extensive search queried non-medical journals, legal, news and businesses sources using the LexisNexis Academic® Database. Searchable terms entered into all news category fields included “MRI,” “children,” “injury,” and “accident.” A secondary search was also performed with EBSCO® and NewsBank® databases with the same searchable items.


We found 9 incidents/injuries leading to liability and litigation (see results table). The incidents/injuries were classified according to the following categories; management (lack of proper patient screening, lack of equipment maintenance, not honoring patient requests); medical (psychological or physiological change); missile effect (objects with ferromagnetic components in magnet room). All nine cases involved a management component.

MRI-Related Incidents/Injuries[figure1]Discussion:

Anesthesiologists are responsible for ensuring the safety of anesthetized patients regardless of the location. Our search found that certain risks may not be apparent to clinicians providing care in MRI. Despite screening protocols used for patients with implantable devices, non MRI-compatible objects are still being brought into the magnet room. Anesthesia provider awareness of dangers in this specialized and unique environment is critical.


1. AJR 2007;188:1-27.

2. Shellock FG. Reference Manual for Magnetic Resonance Safety, Implants and Devices : 2006 Edition. Los Angeles

3. Mitka M. et al, JAMA, 2005.

Anesthesiology 2007; 107: A1599
Figure 1