By Beth Allen
Ironically, at the start of MRI Safety Week 2025, we heard the news of a tragic MRI safety incident in New York that resulted in a death. While the details of how this occurred are still being uncovered, it shows how quickly something like this can happen. There is no benefit to judge the situation or assume this could not happen to me. It is an opportunity to be introspective and identify what we can do better.
It was almost 25 years ago when we heard about a tragedy involving a 6-year-old boy and an oxygen tank that became a missile when it was brought into the scan room, killing him. This event set the stage for more stringent MRI safety recommendations across the country. Many of our technologists have heard of this incident but may not have been even born when it took place. Those of us that were working in the field at the time remember hearing about it and were deeply affected by it. Of course, we grieve for the boy, his parents and the loss they suffered. As technologists, we also had empathy for the staff involved and how that made a mark on them for the rest of their lives. It just takes one poor decision, made in haste, while responding to an emergency.
Events such as these are not a fluke or a freak accident. We know that if we bring metal near the MRI scanner, it will be pulled into the magnet with extreme force. Whether that is a patient gurney, a wheelchair, a floor buffer, a ladder, a gun – anything. It happens fast, before you have time to do anything about it.
Unfortunately, it is easy to become comfortable or complacent when you work in this environment every day. Our workplace becomes like home. For our patients, it may be a place of high anxiety. They may not really listen to us and since we are comfortable, we may not be paying close attention either. Sounds like a recipe for disaster.
Our processes, workflows, checks and balances need to take all of this into account. We need to run a tight ship, since there really isn’t room for error. We need to work our safety checklist every single time.
For starters, zones should be set up according to ACR recommendations. This isn’t always easy if we are in a site built for MRI decades ago. So, if it is difficult to have a barrier to enter Zone III, review what is there. Is it good enough?
Everyone in the site needs to understand the zones and what each designation means. ACR and IAC require clear signage designating the zones.
Zone I is generally the lobby or reception space. This area requires no MRI safety screening.
Zone II is a transition from the general population area and the restricted area close to the MRI suite. It is the patient changing and screening zone.
Zone III is where the technologist operates the MRI scanner and just outside the MRI scan room door. Anyone in this area needs to be properly screened and accompanied by MRI personnel. Prior to entering this space, all ferromagnetic objects should be removed. This includes anyone accompanying the patient.
Zone IV is the entire room the MRI scanner is housed in. Access to this zone is strictly prohibited to those that have been screened and given final clearance by the MR personnel with level 2 training. The magnet is always on.
The door to Zone IV is just a passageway. The door should be opened only to allow passage into or out of Zone IV. The door should be closed immediately after getting from one zone to the other. Every time.
We must account for the fact that the patient may not hear us, may have cognitive decline, or be so nervous they are not processing what we are saying to them.
I heard an ad the other day for the world’s first completely invisible hearing aid. Sounds great for someone needing one. Sounds scary to our MRI team.
It really comes down to the basics. Stay alert, stay alive.
The MRI scanner can do incredible things. It is a truly amazing diagnostic tool. But we have to proceed with caution. Treat Zone IV as the home of an easily angered, powerful wizard. Respect his power and he may grant you the answers to your questions. Casually enter his domain and dismiss his authority, and he will crush you.
This is a wake-up call to anyone that works anywhere near an MRI scanner. This isn’t folklore. It is imperative to the safety of us all to be aware of the danger.
Don’t be the headline. Keep it safe, keep it consistent. Make sure the rules are in place and followed every time.
Thank you for all you do.
