An article in the Los Angeles Times attracted my attention recently. Datelined January 28 2010, it reported that the California State Department of Health had fined 13 hospitals for committing medical errors that in some cases seriously injured and even killed patients.
Some of the errors included:
-the death of a patient who was supposed to be restrained and supervised, but was instead left to repeatedly pull out his tracheotomy tube until he was found unresponsive in his bed.
-intensive care nurses failing to monitor a woman’s oxygen levels; the patient passed out and had to be placed on a ventilator.
-the death of a patient treated in the emergency room for a heart attack where nurses failed to notice that the man’s heart monitor had disconnected and the volume on the patient’s heart monitor alarm was not loud enough to alert staff.
-staff leaving a surgical sponge in a patient. She got so sick she had to undergo a second operation.(Yes,people, it also happens in the US!)
But perhaps the most bizarre medical error reported was the case of a patient on a metal stretcher being sucked in by an MRI machine’s magnetic force, resulting in the patient fracturing her leg and foot. Just so to remind ourselves that such MRI-related injuries are not uncommon, a similar incident was shown in Episode 15 of ER which was screened a year earlier in 2008!
MRI scans have gained in popularity in the last decade with its crystal-clear images and with no radiation involved. It uses magnetic waves instead, but the strength of these waves can be as much as 50,000 times the earth’s gravity. So much so, any metal objects within distance can be pulled with such force to the machine’s magnets to be able to cause serious injuries. Incidents such as scissors flying and oxygen canisters hitting with such force to cause fatal injury have been reported. Not to mention the data on credit-cards being wiped out to render them useless! In fact, those with heart pacemakers and certain artificial heart-valves are usually not permitted to undergo MRI scans.
Yet, despite risk reduction strategies and safety protocols, such untoward incidents do continue to happen. One of the main reasons for this is that many – including healthcare workers -are unaware that the magnets in the MRI scanner are always “on” even though there are no patients inside.
Read here to find out more on the Joint Commission’s recommendations for MRI safety procedures for healthcare workers.
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