Ferromagnetic Sandbags Are Hazardous in Magnetic Resonance Imaging (MRI) Environments
Hazard [Health Devices Jul 1998;27(7):266-7]
A member hospital reported that a sandbag containing ferromagnetic pellets
was inadvertently brought into the magnetic field of a 1.5-tesla magnetic resonance
imaging (MRI) unit. The sandbag, which had been placed in the vicinity of a patient's
groin for site compression and the control of bleeding, had been obscured from the MRI
staff's view by a blanket. As the patient was brought toward the MRI unit, the sandbag was
violently pulled from its position and became pinned to the wall of the MRI tube. The
patient received bruises to her chest and head. Although the MRI unit sustained no damage,
two men were required to remove the sandbag from the bore of the magnet.
MRI units use strong magnetic fields and radio-frequency waves to image
anatomic structures such as the brain and spine. The magnetic field generated by an MRI
unit will attract ferromagnetic objects with considerable force. This attraction, usually
referred to as the "missile effect," poses a significant risk to anyone in or
near the unit who is in the path of one of these objects. ECRI is aware of several serious
injuries caused by patients being struck, pinned, or lacerated by a ferromagnetic object
pulled into the magnet. These objects include oxygen bottles, tools, chairs, ladders,
patient lifts, traction weights, IV poles, laundry carts, pens, hair barrettes, and
In addition to possibly causing injuries, a ferromagnetic object pinned
deep within a tight MRI bore may be hard to reach, and generating sufficient force for its
removal may be difficult. Extensive downtime may also ensue: in an emergency, the magnet
may need to be turned off quickly (i.e., quenched) to extract sizable ferromagnetic
objects, putting the MRI system out of service for up to three days and entailing
substantial financial loss. In the worst case, damage could require replacement of the
magnet, a repair that could cost more than $500,000.
Careful screening of all objects and persons is crucial in ensuring the
safety of the MRI area.
While sandbags are often assumed to contain only sand, some contain
ferrous pellets or iron oxides that add weight to the sandbag without increasing its size.
Several journal articles report cases of a sandbag containing ferrous pellets creating a
hazard in an MRI environment. Reports include dislocation of, and other damage to, the
magnet, as well as damage to the gantry, fan blower, and body coil antenna. And in an
incident similar to the one reported by the hospital, the force needed to remove a 5 lb
ferromagnetic sandbag (dimensions: 5 x 5 x
1½ in) was estimated at 500 to 700 lb.(1)
MRI staff must ensure that sandbags (as well as other objects used for
patient positioning, patient immobilization, and site compression) are brought into an MRI
environment only if they are MRI compatible—that is, nonmagnetizable. Sandbags should
be assumed to be ferromagnetic and should be barred from entering the MRI area unless they
are specifically labeled for MRI use. This restriction includes sandbags that may have
come from other departments (e.g., physical therapy, cath lab). While some facilities have
advocated testing sandbags with a magnet or a metal detector (e.g., a handheld sensor),
ECRI does not believe that this is a reliable or cost-effective screening method.
If sites have existing sandbags not specifically labeled for the MRI
environment and wish to keep using them, they should contact the sandbag supplier to
verify that the component materials are MRI compatible. And if a variety of compatible and
noncompatible sandbags are used throughout a facility, a marking system should be
implemented to identify the ones that are compatible.
The above precautions should also extend to all other possibly
ferromagnetic items, including wheelchairs, stretchers, and IV poles.
- Purchase and use only sandbags that are known to be
MRI compatible and that are so labeled.
- If unsure of the content of a currently owned
sandbag, do not allow it in the MRI environment until it is verified as
nonferromagnetic. Do not bring it near the MRI unit to determine whether it
- Alert MRI staff of the need to check whether
ferromagnetic sandbags have been brought into the area from other hospital
departments (e.g., a site compression sandbag carried in on a patient from
the cath lab). These sandbags could be obscured from view by a sheet or
- Follow the typical precautions used in MRI environments:
- Alert users and other appropriate personnel to
the risks posed by ferromagnetic materials.
- Ensure that the area immediately surrounding the
MRI unit is placarded with the appropriate warnings.
- Ensure that trained staff members are
responsible for physically securing the area.
- Carefully screen for ferromagnetic materials; this includes removing
metallic objects belonging to patients and staff.
- Chu WK, Sangster W. Potential impacts of MRI accidents. Radiol
Technol 1986 Nov-Dec;58(2):139-41.
- Sand Bags [13-439]
- Immobilizers [12-093]
- Magnetic Resonance Imaging (MRI) Units [16-260]
- Positioning Aids [16-223]
Cause of Device-Related Incident
Device factor: Design/labeling error
User error: Incorrect clinical use
Support system failures: Poor prepurchase evaluation; Use of inappropriate devices
Mechanism of Injury or Death