Podcast: The pivotal MRI accident that launched MRI safety

2026 marks the 25th anniversary of the deadly accident that changed MRI safety forever. Series 2, Episode 1 of The Invisible Force podcast on the AuntMinnie Podcast Network begins a three-part MRI safety case study.

This MRI safety failure focuses on the circumstances surrounding the death of 6-year-old Michael Colombini, who went to Westchester Medical Center in 2001 for a post-op MRI and died after a steel oxygen cylinder was rushed to his aid while he was in the scanner.

The Colombini case has been the single greatest reference point for MRI safety for the professional radiology community, according to Invisible Force co-host and MR safety officer Tobias "Toby" Gilk. The event was thrust into the public eye, ultimately leading to the launch of modern MRI safety.

"Many in healthcare have never heard the full story, and so we have lost touch with any lessons that this incident can teach us," co-host and fellow MRI safety educator John Posh explains to open the episode. "It is such a seminal moment in MRI safety that being familiar with it really helps the understanding of everything else that happens after."

The key difference between prior serious MRI accidents and the Colombini incident in 2001 is that earlier incidents were effectively kept out of the press. However, this event brought the missteps to light, effectively raising awareness and launching MRI safety for all healthcare providers.

In the Colombini case, the fateful healthcare encounter stemmed from a fall, suspected skull fracture, and head CT. The CT showed a small brain tumor that prompted an order for pre-op MRI and surgery.

"The news that day was all good -- the playground accident a couple days prior turned out to have possibly saved their son from a horrible death three or four decades later," Gilk noted. "Their son, while looking a bit worse-for-wear after his surgery, was going to be fine."

Follow-up MRIs were ordered to monitor for signs of recurrence. The episode revisits the baseline MRI scan the day after surgery that rocked the family and changed the trajectory of MRI safety. Still sedated and on an additional calming dose at the time, Colombini underwent the baseline MRI scan.

"Here’s where the fact that this building was an addition to the hospital comes into play," Posh notes. "This building didn’t have its oxygen piped in from the main hospital system." There were no alarms or alerts to signal a problem with oxygen flow that would become apparent as the boy's pulse oxygen level began to drop, and personnel struggled with the equipment that supplied supplemental oxygen, according to Gilk.

"The anesthesiologist is watching the Colombini boy desaturate, and he is desperate to get supplemental oxygen to the boy," Gilk recounts. A nurse hands a metal oxygen tank to the anesthesiologist while imaging personnel are trying to restore equipment function from a soundproof room.

Twenty-five years later, Michael Colombini's name should be known to anyone who works in the vicinity of an MRI suite, not as a cautionary tale but as the foundational case that explains why MRI safety protocols exist at all. The last week in July is universally recognized as MR Safety Week in the U.S. in remembrance of Michael Colombini.

"We imagine there was a moment -- just a fraction of a second -- where the anesthesiologist felt the magnet pulling on the tank," Posh said. "In that instant, as the tank was pulling out of his hands, did he realize that a catastrophic accident was happening."

Understanding what went wrong in the MRI scan room -- the infrastructure gap, the missing alarms, the tank handed over in desperation -- is the context that makes every screened patient, every restricted-zone conversation, every second look at what someone is carrying into your suite mean something beyond protocol compliance.

"It seems that everyone in MRI knows the outcome of that accident, but surprisingly few know how it happened, and the absolute Shakespearean tragedy that the story is," Gilk noted. 

Series 2 of The Invisible Force begins where modern MRI safety began. Listen now.

Editor's note: The imaging community and other listeners have been invited to contribute to the The Invisible Force via its Tip Line -- 631-MRI-TIPS (631-674-8477).

Host
Tobias "Toby" Gilk is the founder of Gilk Radiology Consulting. An architect by training, he has spent over 20 years focusing on MRI safety, initially through the architecture and planning of MRI facilities, but growing into the technology, clinical practice, regulation, and economics of MRI safety. Gilk holds both MR Safety Officer (MRSO) and MR Safety Expert (MRSE) certifications from the American Board of Magnetic Resonance Safety (ABMRS). An evaluator of serious reportable events (SRE), he is also a volunteer member of the Technical Expert Panel (TEP) of the National Quality Forum, and co-author of "The Technologist MRI Safety Handbook."

Co-host
John Posh is an MRI educator, safety consultant, and safety auditor with over 35 years of experience in the field of MRI safety and education, working with outpatient facilities, hospitals, and universities. He owns Posh Education in Bethlehem, PA, and currently serves as global director of education and training for Aspect Imaging, chief academic officer-MRI at John Patrick University, and adjunct professor of medical imaging at Rush University.

This episode of "The Invisible Force" is brought to you by AuntMinnie and the AuntMinnie Podcast Network. You can also find it on Apple Podcasts and Spotify. Check out AuntMinnie's full podcast library, including extras, on Apple Podcasts and Spotify.