When severe medical events occur, internal reviews and reports to the Centers for Medicare and Medicaid Services (CMS) are appropriate next steps. But when healthcare workers are injured, the Occupational Safety and Health Administration (OSHA) also becomes involved.
Series 3, Episode 4 digs deep into a 327-page document dump from the California Division of OSHA (Cal/OSHA) and what it reveals about systemic MRI safety failures at Kaiser Permanente's Redwood City Hospital is troubling.
The episode focuses on a 2023 MRI accident in which a nurse was severely injured after being pinned between an ICU bed and an MRI scanner. While Cal/OSHA's official citation faulted the hospital only for failing to keep the MRI scanner room door closed and levied an $18,000 penalty, the investigatory file sent to podcast co-hosts John Posh and Toby Gilk told a far more alarming story.
Among the most striking findings: the hospital's Level 1 and Level 2 MRI safety training materials were virtually identical, differing only in their title slides. Level 2, which is intended for MRI technologists and radiologists, required a 20-question quiz, but contained no additional content beyond what Level 1 employees received. And while radiology department employees had extensive competency checklists reviewed and signed off by supervisors and department directors, the injured nurse, who was a Level 2 designee, had no documented competency review whatsoever.
The episode also scrutinizes a physicist's report completed five months before the accident, in which the hospital received a perfect score on an MRI Safety Program Assessment Checklist by the American College of Radiology (ACR). Posh argues the checklist is fundamentally superficial by asking only whether certain policies exist, not whether their content is adequate or appropriate.
"I’m feeling more and more confident in our prior opinion that the MRI safety problems were systemic at Redwood City Hospital… and maybe even throughout the parent organization, Kaiser," Posh says in the episode. "Since the Cal/OSHA report only cited the open door, they didn’t offer a conclusion about systemic problems, but we're going to suggest it."
The hosts contend that the accumulated evidence points not to isolated failures, but to a pervasive culture of inadequate MRI safety oversight, one that no internal review process caught before a nurse was seriously hurt.
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.
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