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Flying Infusion Pump Hits MRI, Narrowly Missing Child
A child was brought to the Magnetic Resonance Imaging (MRI) room for a brain scan. Accompanied by an anesthesiologist, the child was receiving sedation for the MRI via an infusion pump with a long IV tube. The anesthesiologist was aware that the pump needed to be kept away from the magnet. The pump was placed 10 to 15 feet away from the MRI magnet on top of a garbage can, as is the practice at the hospital--no bracket is used to secure the pump.
When the scan was completed and the patient was to be wheeled out from inside the scanner, the anesthesiologist brought the pump to the foot of the bed to secure it to a bracket there. However, the child made an unusual noise, which caused the anesthesiologist to turn around suddenly. As he did so, the pump flew out of his hand and hit the magnet, which is always on. The impact damaged the pump, but the child was unharmed.
Root Cause Analysis later revealed the following background information: Metal items are kept outside of the MRI room, but an exception is made for infusion pumps, which are allowed inside the room at a safe distance from the MRI magnet. However, at this hospital, no bracket is used to secure the pump, and no markings are present on the floor or elsewhere to indicate what is considered a safe distance. Following this event, the hospital has committed to purchasing MRI-safe pumps and installing brackets in MRI rooms to secure the pumps. Additional staff education and posted warnings have also been put in place. Other solutions such as using metal detectors and double-checking people before they enter the MRI room are also being considered.
Example of Diagnostic Error
False Positive Biopsy
Prescription Error
Systems Errors
Flying Infusion Pump
Printed Prescription
Medical Errors a National Problem
Compunding Medication Error
Pediatric Surgery Errors
Leo Leonidas, MD, FAAP
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