[Analysis of accidents for magnetically induced displacement of the large ferromagnetic material in magnetic resonance systems].

To improve magnetic resonance (MR) safety, we surveyed the accidents caused by large ferromagnetic materials brought into MR systems accidentally. We sent a questionnaire to 700 Japanese medical institutions and received 405 valid responses (58%). A total of 97 accidents in 77 institutions were observed and we analyzed them regarding incidental rate, the detail situation and environmental factors. The mean accident rate of each institute was 0.7/100,000 examinations, which was widely distributed (0-25.6/100,000) depending on the institute. In this survey, relatively small institutes with less than 500 beds tend to have these accidents more frequently (p<0.01). The institutes in which daily MR examination counts are more than 10 patients have fewer accidents than those with less than 10 daily examinations. The institutes with 6-10 MR examinations daily have significantly more accidents than that with more than 10 daily MR examinations (p<0.01). The main mental factors of the accidents were considered to be "prejudice" and "carelessness" but some advocate "ignorance." Though we could not find significant reduction in the institutes that have lectures and training for MR safety, we should continue lectures and training for MR safety to reduce accidents due to "ignorance."