Podcast: MRI safety experts shed light on wishy-washy leadership

When an MRI accident occurs, imaging center and safety leaders may be inclined to scrutinize their own MRI safety culture and assess their risks prospectively. This episode of The Invisible Force podcast on the AuntMinnie Podcast Network serves as a useful case study.

Series 3, Episode 3 explores the U.S. Centers for Medicare and Medicaid Services (CMS) report following the 2023 MRI accident in which a nurse was pinned to an MRI scanner by an ICU bed. Hosts and MRI safety experts Tobias "Toby" Gilk and John Posh reveal the deficiencies in Redwood City Hospital's MRI safety practices at that time, as well as the hospital's corrective action plan established after the facility inspection and accident investigation.

Once again Gilk and Posh frame MRI adverse events as preventable outcomes of system weaknesses.

"For nearly 20 years, most MRI suites have been designed and built following a model called the four-zone model," explains Posh. The industry-standard model and Kaiser Permanente's own policies called for the ability of the MRI tech to directly supervise anyone in the Zone 3 area, Gilk adds.

However, in the Redwood City MRI case, "as soon as the technologist dipped into the control room, she was functionally incapable of directly supervising the people who were in that airlock or Zone 3 space," Gilk noted.

According to Gilk and Posh, while the Redwood City Hospital MRI suite design fell short of the four-zone MRI safety model, it still complied with the California Building Code for MRI facilities, and it met Joint Commission requirements for Zone 3, Zone 4 layouts.

Safe patient handling was a type of "tile puzzle exercise," and it played a key role in the Redwood MRI incident, according to Posh, who suggests a gap between documented policy and actions that day.

The episode also questions Level 2 MRI safety status. Was it treated as a meaningful demonstration of knowledge and judgment or as a credential conferred by mere completion of a brief module?

"Facts of what happened on that day all suggest that the nurse didn't demonstrate the knowledge or competencies that are all supposed to be essential parts of that level 2 designation," says Gilk.

Furthermore, Gilk and Posh shed light on the CMS investigation into the hospital's MR medical director at the time and MRI-specific safety training before the accident.

Ultimately, safety-critical roles require validated competency, not merely exposure to information, suggest Gilk and Posh, pointing to the need for assessment-based training models, periodic revalidation, role-specific curricula, and documentation that distinguishes awareness training from operational competence.

For those interested in a developing a forum for research in patient safety, organizational behavior, MRI safety education, and MRI regulatory policy, this episode distinguishes active failures at the point of care and latent organizational conditions that made those failures more likely.

Listen now.

Editor's note: Those working in hospital safety, state health regulation, CMS, healthcare policy, or MRI can contribute to this story and The Invisible Force podcast 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.