Patient left inside MRI machine for 6 hours—how did no one notice?
Industry Buzz
You know [how] a nurse's recurring nightmare, worst nightmare, is getting to the end of shift and realizing that you had an extra patient that you'd completely forgotten about and have not checked on the entire time? What is the radiology version of that? … I'm thinking it might be this.
—@the.nurse.erica, RN, via Instagram
MRI tech here, it's so much worse than you realize. There is equipment that needs to be put away and in the proper place for the end of day shutdown process as well.
—@breuan, an MRI tech, via Instagram
A routine MRI exam at a large hospital in China has become a stark reminder of how process failures can impact patient safety.
What was expected to be a brief scan—around 30 minutes—became an overnight ordeal after staff failed to remove the patient from the machine after the exam.[]
A breakdown in handoff
Hospital officials said the incident stemmed from lapses in shift-change procedures.[] One doctor reportedly marked the scan as “complete” in the electronic health record at 12:10 am before moving on to other tasks, and incoming staff did not verify whether the scanner was empty.[][]
The patient remained inside the MRI machine until around 6 am, when cleaning staff discovered him.[]
Why didn’t the patient move?
Reports indicate the patient remained immobile in the machine due to concern that movement might be unsafe during or after the scan.[]
While MRI itself is generally considered safe, patients are typically instructed to remain motionless during imaging to avoid compromising image quality.[]
Tongji Hospital issued a public apology and suspended at least two staff members involved with the incident.[2][6] An internal investigation found that violations of established protocols—particularly around shift handovers—were a contributing factor.[]
The hospital said it is revising its procedures to prevent similar occurrences, including strengthening verification steps at the end of exams.[]
What this means for the clinic
While rare, this case highlights how even routine imaging can fail without adequate safety checks.
“You know [how] a nurse’s recurring nightmare, worst nightmare, is getting to the end of shift and realizing that you had an extra patient that you’d completely forgotten about and have not checked on the entire time,” Nurse Erica, RN, a nurse and influencer, said in an Instagram Reel. What is the radiology version of that? … I’m thinking it might be this.”
Radiology departments, especially in high-volume settings, rely heavily on seamless coordination between technologists, radiologists, and support staff.
“MRI tech here, it’s so much worse than you realize,” @breuan, an MRI tech, wrote in a comment on Instagram. “There is equipment that needs to be put away and in the proper place for the end of day shutdown process as well.”
Standardized “room clear” protocols, electronic safeguards, and physical confirmation of patient status are critical components of MRI safety.