A Bay Area nurse was crushed in an MRI accident, highlighting safety concerns

A Bay Area nurse was crushed in an MRI accident, highlighting safety concerns

What was supposed to be a routine MRI scan quickly became a freak accident at a Bay Area hospital.

From the outside, it was a normal February day at Kaiser Permanente’s Redwood City Medical Center. But inside the MRI center, an MRI technologist had just finished a phone call and heard screaming coming from another room.

A hospital bed was pulled uncontrollably into an MRI machine by its magnetic force as seen in photos obtained by KTVU.

A nurse became trapped between a bed and a machine and suffered crushing injuries, according to a Cal/OSHA investigation.

“I was pushed out of bed,” nurse Aina Cervantes told investigators in a report obtained by KTVU. “Basically, I was running backwards, and if I didn’t run, the bed would crush me underneath me.”

Online videos show the sheer power of the machine’s magnets on anything metal. MRI safety advocates say ballistics, burns, and implanted devices are common causes of MRI-related injuries and deaths.

Cervantes suffered a severe laceration that required surgery, which included the removal of two embedded screws, documents showed. The patient, who fell from the bed to the floor at that time, was not injured.

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Although the incident first occurred in February, the investigation was not completed until several months later.

Tobias Gilke, an MRI expert, said that the MRI machine does not stop magnetic attraction once it is attached to an object.

“It keeps pulling and pulling and squeezing to try to bring the magnetically attracted object closer to the MRI scanner itself,” he said.

Gilk’s research into MRI machine accidents includes federal data showing that as the number of scans and examinations increases, accidents also increase, but at a three-fold rate.

(Photo of the MRI accident that crushed Tsar’s nurse Aina Cervantes in Redwood City in February )

It is estimated that thousands of accidents go unreported every year.

“Personally, I find it very frustrating,” Jelke said. “We know that MRI accidents can occur when best practices are not followed.”

The California Department of Public Health’s findings show that the city of Kaiser Redwood “failed to provide radiation services in a safe manner.”

Regulators say systemic problems at the facility began with a nurse and patient care tech left unsupervised without MRI staff. No one was examined, including the patient. The door to the magnetic chamber was left open. The safety alarm system never sounded.

The state said it cannot estimate how often such incidents will occur and acknowledges there are no regulations to specifically address MRI centers.

“For us to operate an MRI center safely, safety education is critical,” said Dr. Emanuel Canale, a radiologist at the University of Pittsburgh.

Kanal studied hundreds of incidents and said safety training is crucial. He stressed that MRI staff should have the same minimum standards as airline pilots.

“From an aviation safety standpoint — standardization, certification, recertification, making sure you’re at the top of the game — to me, these are important aspects of what we need at MRI to make sure we reduce these incidents as much as possible,” Canale said.

KTVU obtained Kaiser’s MRI safety policy and found several violations that contributed to the accident.

The policy states that employees are not permitted to enter the magnet area without proper screening, stretchers and other metal objects will not be moved into the MRI room, and the MRI room door must remain closed at all times.

Incident investigation records show that some required safety training never occurred for some employees, and the facility also failed to test the door alarm annually as recommended.

“Numerous safety failures… created a culture of unsafe practices,” the DPH investigation stated.

Kaiser Permanente declined an interview but responded in a statement.

“Our teams responded quickly and participants immediately got the care and support they needed,” said Sheila Gilson, senior vice president of the Kaiser Permanente San Mateo region. “This was a rare event, but we are not satisfied until we understand why the incident occurred and implement changes to prevent it from happening again,” he added.

But sources claim this was not the only incident that occurred at Redwood City Hospital. A photo provided to KTVU shows a medical equipment cart stuck in an MRI scanner. Kaiser said it was likely due to an incident in March 2015 in which no patients or staff were injured.

“As an organization committed to continuous learning improvement, Kaiser Permanente fully investigated the incident and used what we learned to make specific process changes to enhance safety,” Gilson said in a statement.

MRI safety experts told KTVU that without adequate monitoring or mandatory safety requirements, patients could be put at risk.

“It has become important for us to make sure that we limit access to the site only to people who need to be there,” Canal said. “We can control what and who gets in and how they are exposed to what.”

Kaiser faces an $18,000 fine from Cal/OSHA for the errors and workplace injury incident.

“It’s not just the last barrier or the last individual failing,” Gilke said. “It’s a failure of many protections or preventions. My first thoughts were – not again.”

Brooks Jarosz He is an investigative reporter for KTVU. Send him an email at brooks.jarosz@fox.com And follow him Facebook And X@brooksKTVU

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