A patient on the MR bed in a Mountain View, California, imaging center dodged a bullet when a wheelchair was rolled into the suite and flew into the magnetic bore. Although nobody was hurt, the avoidable — and potentially fatal — incident highlights issues with reporting standards for MR adverse events.

The metal chair was reportedly brought into the suite by a trainee and narrowly missed the patient, according to KTVU.

MR safety expert, Tobias Gilk, reported the event to the news station, along with images that he said a witness provided from Sutter Health's Mountain View Center Imaging, back in April.
"There was a patient on the table and this trainee brought the non-MR-safe wheelchair into the room, then the magnet attracted it and went flying at the scanner," he told the station. "My frustration comes out of the fact that these are almost 100% preventable through existing best practices."

KTVU described the difficulty it had determining reporting standards from regulatory authorities.

In an email to the news station, the California Department of Public Health said that its radiological health branch was informed, through a public inquiry, of an MR incident at a health care facility in Mountain View, but that "MRI is outside their jurisdiction" and "all questions should be asked of the California Medical Board" instead. The California Medical Board then referred them to the Department of Health.

According to Gilk, the incident illustrates why there should be an agency that standardizes reporting and enforces consequences for adverse events in the MR suite.

Last year, another California healthcare facility, Kaiser Permanente Redwood City Medical Center, experienced a similar event. In that instance, a nurse was pinned between the MR scanner and a hospital bed, and the hospital received an $18,000 fine.

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