ISMP Alert - Hydromorphine Prefilled Syringe Attracted by MRI Magnet
The Institute of Safe Medication Practices (ISMP) recently shared information about an incident involving an unopened DILAUDID (HYDROmorphone) prefilled syringe (SIMPLIST, Fresenius Kabi), that was brought into a room with a magnetic resonance imaging (MRI) scanner. The Simplist package contains a StabilOX canister that holds iron oxide, which serves to prevent oxidation of the drug. The iron oxide in the canister is ferromagnetic. In this case, “…the magnetic pull from the MRI scanner drew the Simplist package to the magnet with considerable force. No one was harmed in the incident, but the enclosed glass Dilaudid syringe apparently shattered. Both Dilaudid and morphine syringes in Simplist packaging have this StabilOx canister.”
ISMP has confirmed the canister’s ferromagnetic properties with the StabilOx manufacturer, Multisorb, but they have not independently tested the canister in a MRI room. ISMP states it is not known if other prefilled syringes might also contain ferromagnetic materials. IMSP notes that the ferromagnetic properties come from the StabilOx canister – not from the syringe itself or any of its components. There is no metal in the syringe itself and the blister package has aluminum backing that is not ferromagnetic.
Cases like this serve as an excellent reminder of the importance of MRI safety. Key safety practices include:
- Using the four-zone approach to provide progressive restrictions in access to the MRI scanner.
- Education of MRI staff on materials that may contain ferromagnetic properties
- Screening all persons entering the MRI environment for magnetic objects in their bodies, on their bodies or attached to their bodies. This should include patient medication. Magnetic objects on or attached to patients’, family members’ or staff members’ bodies should be removed, if feasible, before these individuals enter the MRI scan room.
ISMP recommend that MRI technicians be informed of the above issue with Simplist syringes that contain StabilOx canisters. A link to the compete alert is provided below, and MRI staff are encouraged to read the alert in its entirety.
Follow the links below to read the ISMP alert and for example policies related to MRI safety.
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