MRI Safety 10 Years Later

In the summer of 2001, the radiology world was shocked to learn of an accident at Westchester Medical Center in New York state in which 6-year-old Michael Colombini was killed while being prepared for an MRI exam. Sedated and positioned in the scanner, the child`s oxygen saturation levels began dropping quickly. After the piped-in oxygen serving the MRI scanner room malfunctioned, the anesthesiologist attending the child called for oxygen. A nurse, who was not part of the MRI department staff, responded to the anesthesiologist`s calls and, meeting the anesthesiologist at the door to the MRI scanner room, handed him a steel oxygen tank. When the oxygen tank was brought into the MRI scanner room, the profound magnetic strength of the MRI scanner drew it out of the anesthesiologist`s hands and into the scanner, where it struck and killed the young boy.

Nearly all practitioners who have some responsibility for safety in MRI—risk managers, technologists, compliance officers, administrators, patient safety officers, and radiologists—are aware of this most infamous MRI accident: the 2001 death of Michael Colombini. Ten years after this tragedy, it is appropriate to measure what we know about it, how that knowledge has reshaped MRI safety, and how improvements in MRI safety measure up.