Siemens has completed an investigation of the reported event.The root cause was determined to be user error.The system was checked by siemens service and found to be operating within specification.No hardware problem was found which would explain the reported fracture to the patient's shoulder.The service engineer advised the operator to move the table while checking the patient's condition and recommended using the stop button in an emergency.The root cause for the fracture is a direct skin-to-cover contact of the left elbow to the magnet bore wall.This represents an inadequate or incorrect positioning as described in the magnetom operator manual* on chapter 2 "safety", page15 and pages 20 and 21.Please always follow the instructions given in the operator manual, regarding correct patient positioning 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.- to ensure this distance, use positioning aids, e.G.Blankets made of linen, cotton, or paper, or dry material that is permeable to air.The manufacturer is not considering further actions resulting from this event as no systematic error has been recognized.
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