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NJ Department of Health issues warnings: What's in your sandbags?

From the June 1, 2006 issue

The NJ Department of Health and Senior Services just alerted all NJ facilities about a potentially serious event involving a sandbag that was actually filled with metal shot, not sand (www.nj.gov/health/hcqo/ps/). When a post-cardiac catheterization patient underwent an emergency MRI, the sandbag in his groin area (to apply pressure to the catheter access site) flew towards the MRI magnet. Luckily, the bag did not hit the patient’s head. It adhered to the rim of the machine until he could be safely removed. Unknown to staff, the sandbag contained metal shot, even though this and other bags had been described on order forms, product numbers, invoices, and packing slips as sandbags. The alert suggested examining all sandbags to ensure that they do not contain metal, and replacing any metal-filled bags. In 2001, the Veterans Administration (VA) issued a similar advisory after a sandbag flew into the magnet, pinning a patient’s forearm to the side (www.va.gov/ncps/alerts/MRIgenalert.doc). The sandbag contained iron pellets. The VA suggested that all items should be considered unsafe for the MRI environment until "proven" otherwise, but they warned not to test a sandbag with an MRI magnet to check compatibility, as the consequences could be catastrophic. ECRI issued a similar alert in 1998 with recommendations, including the use of sandbags that are known to be MRI compatible and so labeled (www.mdsr.ecri.org/summary/detail.aspx?doc_id=8075).

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