With another example of a preventable MRI accident, Season 3 of "The Invisible Force" podcast on the AuntMinnie Podcast Network begins.
In this case, a nurse sustained penetrating injuries from an ICU bed that was pulled and pinned by an MRI scanner magnet. MRI safety experts and educators Tobias "Toby" Gilk and John Posh reconstruct what happened at Kaiser Permanente's Redwood City hospital in the San Francisco Bay area of California the morning of February 23, 2023.
Gilk and Posh say a combination of communication breakdowns, unclear emergency authority, workflow pressure, staff training gaps, and system-level risk led to the workplace accident. They dissect each force in Season 3. Listen to the first episode now.
MRI scheduling mix-up
The series of events began when the imaging department squeezed an emergency department patient into the MRI schedule. The ER-to-MRI request turned into a cascading communication failure, according to Gilk and Posh.
"It only took one scheduling mix-up like this to completely derail the day in MRI in their small community hospital," Posh notes. However, "this patient, despite being in the ICU, was far from the most difficult to manage the transport for," he said.
At the MRI unit, the bed was wheeled too close to the magnet's forces. Plus, the nurse may have been relatively new to this hospital. The episode reveals one of the key turning points in the Redwood MRI accident.
The 500-lb. hospital bed reached its "launch point." As the nurse moved the patient toward the scan room, the MRI scanner's magnet force yanked the bed, pinning the nurse between the bed and the MRI scanner.
Picture this: the nurse is pinned against the MRI scanner, the patient is being pulled away, and the bed is levitating. A safety analysis of the incident points to policy ambiguity around the circumstances under which staff should initiate an emergency magnet shutdown, or quench.
Emergency MRI quench decision
Quench would have been the recommended response in this emergency, according to Posh. Instead, the MRI technologist tore the nurse free from between the bed and scanner, he said.
"In that life-or-death moment, the MRI tech was unclear whether she had the authority to quench the magnet ... fearing repercussions if she quenched the MRI scanner without authorization and unwilling to wait for an official green light from management as she watched the nurse bleed out," Posh said.
At the end of the ordeal, the patient was not injured, but that was not the case for the nurse, who was partially impaled by the ICU bed.
This is "the poster child" example of when the quench button ought to be used, Posh emphasized, adding that Kaiser Permanente policy at the time wasn't clear enough to describe a clear course of action for the tech.
The American College of Radiology (ACR) Manual on MR Safety advises that MR safety events are typically related to unsafe practices, failure to follow MR safety policies and procedures, or gaps in those policies and procedures.
Listen to Season 3, Episode 1 now.
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.
