Siemens has completed an investigation of the reported event.There was no serious injury associated with this issue.It was reported that a patient suffered 2nd degree burns (15 mm blisters) on both upper inner thighs.The medical team caring for the patient performed medical treatment.As no further information regarding the medical treatment has been received a report of the event was submitted in the abundance of caution.Siemens experts analyzed the images generated during the patients' examination.The complete examination of the patient's lower extremities lasted 32.6 min with an active scanning time of 26.4 min.No abnormality was found which would indicate a system malfunction.The measurement was performed in the first level (fl) operating mode.The sar values were within the limits defined by the mr safety standard (iec 60601-2-33), i.E.The maximum applied sar was 21% of the first level mode limit.The applied rf in this case should not represent a risk under normal circumstances and scan conditions.Furthermore, the patient absorbed 12.5 wmin/kg which is clearly below the limit of 240 wmin/kg defined in the mr safety standard (iec 60601-2-33).The system was checked by a siemens service engineer and no deviations were found, that could have led to the burn.No hardware or software problem was found that would explain the reported blisters on the patient's upper inner thighs.It is visible on the mr images that the thighs were touching each other.There was no pad between the upper thighs.Therefore, the root cause for the burns is a rf current loop that may be generated when parts of the patient's body touch.This effect and the preventive measures are described in the magnetom family operator manual - mr system syngo mr e11 (pages 19 - 21).Print no.Mr-02501.621.01.02.02.The instructions given in the operator manual, regarding correct patient positioning should always be followed in order to avoid such incidents in the future: always position the patient so that the patient's arms are aligned with the torso and ensure that hands, arms, and legs do not touch (minimum distance: 5 mm); ensure that the minimum distance of 5 mm is maintained between patient and tunnel covering; and, to ensure this distance, use positioning aids, e.G.Blankets made of linen, cotton, or paper, or dry material that is permeable to air.There is no indication of any malfunction of the system.No further actions are planned by the manufacturer as no system malfunction was identified.
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