The unfortunate incident highlights two critical points.
(1) Even detailed patient guidance on what is acceptable and unacceptable in
an MRI suite may not result in appropriate patient or accompanying person
action. In this case, both the patient and the accompanying person (the son)
signed a declaration acknowledging receipt of the instructions but failed to
remove the metallic object (the gun).
It is possible that the guidance was overlooked or dismissed as a formality
because the patient and her son were preoccupied with the upcoming procedure
and its potential outcomes. It is possible that this was an unintentional,
honest mistake, but one with serious consequences because the son was used
to carrying the firearm as a habit and may not have given it much thought.
There are several consent and procedural aspects in healthcare, and the
importance of each one may not be fully understood by the patient and the
accompanying person.
(2) MRI suites should consider incorporating the use of specialized garment
even for patient and accompanying person. This reduces the possibility of
any additional external metallic or prohibited objects. This may be
difficult to implement for all patients, but it should be considered
mandatory for all accompanying persons. Aside from the guidance, this may
help to limit the entry of unwanted objects into the MRI suite.
MRI injuries are uncommon; however, given the potential for serious
consequences, they must be avoided to the greatest extent possible. The
approach must include a balance of health education, guidance, and practical
actions that patients and caregivers, as well as the health care system, can
implement.
To avoid future MR accidents, it is time to implement the guidelines and
apply the vigilance that the airline industry does.It's time to reinforce
AsiaSafe campaign on MR Safety.
Dr. Rijo Mathew Choorakuttil, MR safety Ambassador, AOSR.
Emeritus Prof. Kwan Hoong Ng, Chair, AsiaSafe, AOSR.
References:
• Murphy H, Gun goes off during MRI, injuring patient's son. Accessed online
on February 16, 2023,
https://healthimaging.com/topics/medical-imaging/magnetic-resonance-imaging-mri/man-shot-his-own-gun-mri-suite?fbclid=IwAR0Yh2fa4WK8b8_jjs3lPNogUkBIyaUD-aP_HSN6Z_wamGF-Cq2MU80g_BI
• Lawyer dies after his hidden gun goes off during MRI scan. Independent
UK.Accessed online on February 16, 2023,
https://www.independent.co.uk/news/world/americas/brazil-lawyer-death-mri-gun-b2279514.html
