title: Management of a sandbag accident in an MRI unit.
abstract: Our aim is to report the cause and management of a ferromagnetic sandbag accident that occurred when an unconscious patient was sent for brain MRI. A 2-kg sandbag had been placed in the vicinity of his right groin to aid hemostasis after a femoral venous puncture for thrombocytopenia. His clothing and blanket had not been examined thoroughly before he was moved to the scanner and the sandbag went unnoticed. Its attraction to the scanner and adherence to the scanner rim resulted in a minor abrasion and bruise on the patient's face. We decided to manually remove some of the pellets from the sandbag after cutting the vinyl bag at one corner with a nonferromagnetic screwdriver. Piece-meal removal of about two-thirds of the pellets facilitated removal of the remaining pellets and the sandbag as a whole. The word "sandbag" is misleading and led to a lack of communication between the clinical team and the MRI staff and failure by the MRI staff to recognize a sandbag as a ferromagnetic object. Careful manual removal of small amounts of pellets can be used to avoid more time- and labor-intensive strategies to deal with a sandbag accident (e.g., magnet quench or ramp-down). Installation of a ferromagnetic material detector to screen patients before entering the scanner room is recommended.
authors.affiliation: Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, 116, Taiwan.
authors.forename: Chee Hwee
authors.initials: CH
authors.lastname: Lee
authors.affiliation: Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, 116, Taiwan.
authors.forename: Ming-Fang
authors.initials: MF
authors.lastname: Lin
authors.affiliation: Department of Radiology, Wan Fang Hospital, Taipei Medical University, Taipei, 116, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, 110, Taiwan. Electronic address: wingchan@tmu.edu.tw.
authors.forename: Wing P
authors.initials: WP
authors.lastname: Chan
mesh_terms: D003288:Contusions / Q000209:etiology*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000295:instrumentation*; D059346:Magnets / Q000009:adverse effects*; D008297:Male; D019300:Medical Errors / Q000009:adverse effects*
keywords: Ferromagnetic material; Hazard; Magnetic resonance imaging (MRI); Projectile incident; Safety