Previous Abstract | Next Abstract
Printable Version
A1596
October 16, 2007
9:00 AM - 11:00 AM
Room Hall D, Area G,
Off the Radar, but Still on the Screen: MRI Fatalities Reported in the Non-Medical Literature
Lauren K. Hoke, B.S., Thomas A. Taghon, D.O., Yvon F. Bryan, M.D.
Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
Introduction: Pediatric anesthesia departments are actively involved in creating sedation and anesthesia services in radiology departments (1). The MRI suite is considered a potentially hazardous environment and conflicting information exists in fatality reporting (2). Despite risks of MRI, there seems to be under reporting of mortality in the medical literature (3). We sought to determine the incidence of death in MRI reported in the non-medical literature.

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,” “death,” “children” and “fatality.” A secondary search was also performed with EBSCO® and NewsBank® databases with the same searchable items. No medical journals, databases or any other source were searched.

Results: We found 10 deaths reported in the non-medical literature (1993-2005); 3 pediatric and 7 adult patients. We categorized deaths into 4 groups: management (screening, not following safety guidelines), missile (flying metallic objects), monitoring (improper patient monitoring) and medical (over-sedation, drug-related incidence).[table1]Discussion: MRI-related fatalities have been reported in both the medical and non-medical literature. We found discrepancies of MRI-related deaths reported in the non-medical literature and the medical literature. This suggests a more frequent occurrence of MRI-related deaths reported in the non medical literature because litigation may be involved (4). Other contributing factors include an increased likelihood of breaching safety guidelines secondary to higher patient volume and sicker patients. Most MRI deaths seem preventable, thus deeper understanding of risk in MRI must be studied.

Refs:

1. Int Anesthesiol Clin. 2006 Winter;44(1):65-79.

2. JAMA 2005;294:2145-8 .

3. Anesthesiology 2005;A1300

4. McNeil DG. New York Times. August 19,2005.

Anesthesiology 2007; 107: A1596
Deaths in MRI
YearSourceAge (yr)Country reportedInitial EventReason for DeathCategory
1993Chicago Tribune²60US (IL)Improperly assembled ventilatorDeclining oxygen levelsManagement
1993Atlanta Journal & Constitution¹13US (GA)Drug allergyRespiratory difficultiesManagement
1997Mainichi Daily News¹42JapanIV contrast given to wrong patientContrast allergyManagement
1998KOMO News Four¹Adult³US (WA)Claustrophobic patient sedatedOver-sedationMedical
1998Hospital Litigator Reporter¹Adult³US (MS)Patient not screened for pacemakerPacemaker malfunctionManagement
1999Philadelphia Enquirer²18-month oldUS (NJ)Patient not monitoredRespiratory failureMonitoring
2000Businessworld (Philippines)¹61PhilippinesNo recorded medical history, patient not monitoredOver-sedationMonitoring/management/medical
2002Daily Telegraph¹Adult³AustraliaPatient not screened for pacemakerMIManagement
2004The Express¹83EnglandPatient screened, pacemaker not notedMIManagement
2005Massachusetts Lawyers Weekly¹12US (MA)Down's patient sedatedCardiopulmonary arrestMedical
¹ is a source in LexisNexis© Academic, ² is a source in NewsBank©, ³ indicates an adult patient of unknown age