Questions arose in the days immediately following a serious Redwood City hospital MRI accident in February 2023, but it took months for the news story to break, according to MRI safety experts and educators Tobias "Toby" Gilk and John Posh.
On the other hand, MRI community insiders quickly learned what happened and where it happened, according to the hosts of "The Invisible Force" podcast on the AuntMinnie Podcast Network.
In the first episode of this Season 3 case investigation, Gilk and Posh recreated the sequence of events at Redwood. They say a combination of communication breakdowns, unclear emergency authority, workflow pressure, staff training gaps, and system-level risk led to the workplace accident in which a nurse was pinned to the MRI scanner by an ICU bed.
The series of events began when the imaging department squeezed an emergency department patient into the MRI schedule. Episode 2 picks up with the injury, chaos, the MRI accident investigation, and incident reporting.
"Over that following weekend, several brave and generous people had posted in online radiology communities not only pictures of the ICU bed caught in the MRI scanner, but also the name of the hospital where it had occurred," Gilk recalls. "In these cloistered online communities, we knew what had gone terribly wrong, as well as where it had happened."
An online search for more information about the hospital at that time produced recent news stories about “A” grades in patient safety, but no news about the MRI accident, according to Gilk.
"People close to Redwood City Hospital who were willing to message us shared what they’d been hearing, and it wasn’t looking good," Posh said. "Some early rumors had even suggested that [the nurse] had died from her injuries ..."
For this episode, Gilk recalls his attempts to gather information from the hospital following the accident.
"We had begun to develop a number of ‘unofficial’ channels into the Kaiser [Permanente] organization, but those people were limited in what they knew if they were more than a step or two removed from the Redwood City radiology department," Posh said.
KTVU reported the incident October 27, 2023.
At what point did this MRI accident report reach the California Department of Public Health (CDPH), the Occupational Health and Safety Administration (OSHA), or the Centers for Medicare and Medicaid Services (CMS)? Did the accident trigger an immediate jeopardy citation? Who had the formal report?
"When CMS took an interest in this accident, it was actually CDPH personnel who were doing the legwork for them," Posh noted.
Gilk and Posh reveal details about their investigation. Learn about the plan of correction as well.
Listen now for the full story.
Editor's note: Since this accident, the National Quality Forum (NQF) updated its list of serious reportable events in relation to MRI operations. The change established a common standard for measuring and tracking patient safety events. 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.
