H3: the investigation by ge healthcare (gehc) has been completed.The system was evaluated and no failures were noted that would contribute to a patient warming event.According to the information available in the patient warming questionnaire provided by the customer, no pads were used to prevent contact with the magnet bore or to prevent the creation of body loops (hand to thigh, thigh to thigh, etc.) per ge recommendation.In addition, the coil cable was positioned without pads, which are to prevent the creation of loops and contact with the patients skin.Based on this information, the likely primary root cause of the incident is â incorrect use of padding the operator documentation describes the appropriate safety measures for padding patients for mr exams.In addition, section conductive material heating states: before scanning, warn patients with permanent eyeliner or other metallic ink tattoos about the risk of skin irritation and instruct them to get prompt medical attention if they experience severe discomfort following an mr exam.The mr operator has the final responsibility for the use and placement of non-conductive mr compatible padding and preparation of the patient, prior to starting the mr exam procedure.No further actions are planned by gehc.
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