The oxygen cylinder was already on the pallet on which the patient was brought into the suite; during the scan, it was shifted about two meters and was sucked into the device, killing the patient, KBS News reported. The exact cause of the accident is unclear, and police are investigating, the news outlet said. There was no closed-circuit television (CCTV) in the MRI suite, according to KBS.
"When operating the MRI machine, there are usually no metal objects around it because of the strong magnetic force," a police official quoted by KBS said. "The hospital also knew about this but explained that the patient was in critical condition at the time and could not [be taken] off the oxygen cylinder."
This is the second fatal accident in a month involving MRI. In September, a worker helping to move an MRI scanner from the fourth to the first floor of the University of Utah Hospital in Salt Lake City died when the scanner fell to the ground.
These kinds of clinical MRI accidents just shouldn't be happening, according to MRI safety advocate Tobias Gilk, senior vice president of Radiology-Planning, founder of Gilk Radiology Consultants.
"Despite being a 'never event,' MRI magnetic projectile accidents still continue to happen pretty regularly, and radiology should hang our heads for that," he told AuntMinnie.com. "The fact is that almost nowhere in the world are there actual explicit rules or requirements to follow the long-established best practices that would help prevent exactly this sort of accident."
The event in Korea echoes a 2018 incident in India, in which a 32-year-old man visiting his mother-in-law in Nair Hospital in Mumbai was killed when an oxygen cylinder he was carrying pulled him into the MRI bore. It was later reported that the metal detector in the room wasn't working properly and that a hospital staff member was on the phone when the accident occurred.
The death in South Korea has occurred 20 years since 6-year old Michael Colombini was killed when a hospital staff member brought a portable oxygen tank into the MRI room; the tank was sucked into the MRI and struck the child in the head. Colombini's death kicked off what has now been a decades-long effort to prevent these kinds of events.
"Given that 2021 is the 20th anniversary of the Michael Colombini accident, we should be deeply embarrassed to see carbon-copy accidents continue to occur decades later," Gilk said. "We know better -- or at least we should know better."
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