“MR conditional” respiratory ventilator system incident in a 3-T MRI environment

The misunderstanding of the labeling for an “MR conditional” respiratory ventilator system resulted in the placement of this device, which had substantial ferromagnetic components, too close to a 3-T magnetic resonance (MR) system, causing a projectile incident. Magnetic resonance imaging health care professionals should be aware of the potentially dangerous consequences when such medical devices that have Food and Drug Administration-approved MR conditional labeling are brought into the MR system room. Recommendations to prevent future incidents are provided herein.