Death Link to Hospital Scan

  By Jeremy Calvert and Tanya Taylor

From the  Herald Sun  page 10
Thursday April 13 2000-04-13
News Corporation   Melbourne Australia

The Alfred Hospital has announced a review of its safety procedures after the death of a man whose pacemaker malfunctioned during a magnetic resonance imaging scan.
Hospital spokesman David Faktor admitted safety procedures were not properly followed when an elderly man dies during MRI treatment on April 1.
"The procedure was partly adhered to but we believe if it was fully adhered to this would not have happened." he said.
Electronic pacemakers operate with sensitive metal switches that are disrupted by the massive magnetic charge of MRI equipment.
Standard safety procedure is designed to identify the existence of a pacemaker or any other sensitive metal object prior to treatment.
"Patients are given very detailed forms asking about 25 questions and then a radiographer will actually sit down and verbally go through those questions to clarify anything that may be uncertain," Mr Faktor said.
The patient involved in the fatal incident was twice asked if he had a pacemaker, but inexplicably failed to provide the information.
But Mr Faktor said the onus for thorough checks lay firmly at the feet of the hospital.
"We have to be vigilant and check more against other records and so on," he said.
Mr Faktor said the checking and crosschecking system at the Alfred has been over-hauled as a result of the death.
"We have now undertaken an investigation on every aspect leading up to an MRI (scan) and new safety checks at each of those levels have been incorporated," he said.
One cause fro concern is that patients may be suffering from clouded judgement because of illness or drug treatment at the time of questioning.
"We now have a quadruple check against patients who may be perhaps delirious, stressed r confused," Mr Faktor said.
At present, if thee are any communication difficulty with a patient, a preliminary X-ray is used to discover if there are any foreign metal objects in the body.
The hospital ruled out making this a standard procedure.
A spokeswoman for the Health Minister John Thwaites said he had ordered a report from the Alfred.
She said that a coronial inquest would be held if it was deemed necessary.