Description:
Cal/OSHA investigated the Redwood City MRI accident that nearly killed an ICU nurse. The hospital received one citation. But the investigative file ran 327 pages—and buried inside were clues to a much bigger MRI safety story.

In this episode of The Invisible Force, John Posh and Tobias Gilk dig into the Cal/OSHA investigation of the 2023 Redwood City Hospital MRI accident, in which an ICU bed was pulled into an MRI scanner, pinning and seriously injuring a nurse.

The official Cal/OSHA citation focused on one hazard: the failure to keep the MRI scanner room door closed. But the agency’s investigative file contained much more—employee interviews, MRI safety training materials, competency records, hospital policies, an internal incident report, and a physicist’s evaluation performed just five months before the accident.

Those documents raise troubling questions. Why were the hospital’s Level 1 and Level 2 MRI safety training programs essentially the same? Why did the MRI technologist have pages of documented competency assessments while comparable MRI safety competency documentation for the injured ICU nurse was absent from the Cal/OSHA file?

And then there’s one particularly remarkable document: an MRI Safety Program Assessment Checklist completed five months before the accident that gave the hospital passing marks on every scored item.

How could an MRI safety program receive a perfect assessment—and months later experience an accident that nearly killed someone?

The deeper John and Tobias dig into the Cal/OSHA file, the bigger the question becomes: were the systems intended to identify MRI safety weaknesses actually capable of finding them before someone got hurt?

Show Notes:
327 Page Cal/OSHA Report (56 MB)

Transcript:
“Do you know what I’m holding in my hand?”

“No, sir.”

“It’s a document entitled MRI Safety Program Assessment Checklist for Redwood City Hospital’s MRI program.”

“Okay.”

“And do you know what it says?”

“No, sir.”

“It says that the MRI safety program passed review.”

“That’s a good thing, right?”

“Five months later, a nurse gets pinned between an MRI scanner and an ICU bed.”

“I… I don’t understand where you’re going with this.”

“What happened?”

“Sir? Well, the ICU bed got sucked…”

“I know that! I’m asking how we got a passing MRI safety assessment and then nearly killed somebody.”

Hello and welcome back to the third series of the Invisible Force Podcast. Invisible Force is an investigative, documentary podcast about MRI accidents, patient safety failures, healthcare mysteries, and the hidden risks of modern medicine. This season is dedicated to an MRI accident in which a nurse was badly injured when she was crushed by an ICU bed. This accident occurred in early June, 2023 in California, and ripples from this accident are still with us today. But before we pick up our story from the prior episode, this is a great time to reintroduce you to the co-hosts of our podcast.

I’m John Posh, an MRI technologist, MRI educator, and longtime advocate for MRI safety practices. I’m also chief academic officer and MRI program director at one university and adjunct faculty at another. I teach MRI safety multiple times per year.

And I’m Toby Gilk, a certified MRSO and MRSE, an MRI facility architect, safety consultant, and a co-author of a new MRI safety textbook, The Technologist’s MRI Safety Handbook.

In our prior episodes we painted the picture of the enforced silence that descended on the hospital and its people, and we looked at the CMS accident investigation process. But because it was a nurse who was injured, this accident also fell into the jurisdiction of another investigative body that doesn’t usually get entangled in MRI accidents. That investigative body was the California Office of the Occupational Safety and Health Administration, or Cal/OSHA.

In September we were notified that the Cal/OSHA report was complete. We weren’t quite sure what to expect. The CMS report of what they found wrong was detailed in thirteen half-pages, so maybe we’d get something like that. We weren’t really prepared for what we got.

First, the Cal/OSHA report wasn’t really a report at all. There was a copy of a letter that indicated they were classifying the event as “serious.” It was an eight page citation and notification of penalty document, and a couple of pages that identified that inspections had been conducted to verify that corrective measures had been taken.

Together, these dozen pages identified a grand total of one cited violation. “The employer failed to identify, evaluate, and correct the hazard of not ensuring that the door to the MRI room zone four in the MRI suite was closed at all times as specified in the employer’s MRI safety guidelines.”

If that was all we got from Cal/OSHA? We would have been sorely disappointed and this would have been an exceptionally short episode.

But what Cal/OSHA gave us was far more than those dozen pages on letterhead. They appeared to have sent us the entire investigatory file, or at least 327 pages worth. Bundled in the document were copies copies of interview transcripts, inspection checklists, violation checklists, the hospital’s patient transport MRI safety checklist, copies of the Kaiser Level I and Level II training materials, training completion certificates, employee competency checklists, building floor plans, MR physics evaluation reports, and the facility’s own internal accident reports.

So let’s start with that Kaiser Permanente in house incident report. Buried near the very end of the Cal/OSHA document dump was this document, which was a grand total of four mostly empty pages, in total about four hundred words.

Wait. So the Cal/OSHA document was more than three hundred pages and the Kaiser Incident Report was four hundred words. I have longer cat converse I have longer conversations than that with the barista at my favorite coffee shop.

Well, there were several photos taking up white space, but yes, in terms of what it actually said, it contained a very terse sequence of events of the accidents, a bullet point list of eight or ten items of what the immediate response to the accident ought to be. It reads almost as if it was a day of the accident document, indicating that it was going to be addressed and responded to, but how it was addressed and what those responses were, those aren’t part of the Kaiser Permanente incident report.

We got some details on what Kaiser Redwood City’s response would be in the CMS report. Did any of the Cal/OSHA documentation detail the hospital’s responses? Any of their MRI safety fixes?

Oddly, no.

So there’s three hundred and twenty seven pages of content, only one identified problem in the citation, and no prescribed corrective measures?

There’s just one entry that confirms that an inspector found that the hospital had remediated the problem. But remember that the only thing the hospital was cited for was leaving the MRI scanner room door open. So that might have been the only thing that the inspector was looking at in the follow-up inspection.

So if the Cal/OSHA inspectors did follow up with a visit and found the MRI scanner room door closed, that could have been how the whole OSHA investigation resolved?

I suppose so.

But the hospital was penalized by Cal/OSHA, right?

yes. the documents they sent us indicate that Cal/OSHA was assessed an eighteen thousand dollar penalty to the hospital.

Eighteen grand, huh? That doesn’t sound like a very painful penalty. Not a not to a healthcare system that measures annual revenue in billions.

I have a sneaking suspicion that the hospital paid more in the salaries of their staff, the regulatory and compliance people over the course of the investigation and report than they paid in that penalty. That was probably just sofa-cushion change at that point.

So for Cal/OSHA, all of this is simply because the door to the MRI scanner wasn’t closed?

Well, that might have been what they identified in the official citation, but as we said, the data dump that they sent us indicates that they looked at way more than whether the just the door was left open.

From our last episode, you probably remember the summary statement from the CMS investigation. It states, “The many safety failures by the MRI and non-MRI personnel created a culture of unsafe practices, leading to the severe injury of one hospital personnel and the potential for injury to one patient.” And our feeling is that it was actually the culture of inattention that made this individual safety failure much more likely. Did the Cal/OSHA documentation support either of the earlier CMS findings or our interpretation that there was a substantial culture problem?

Yes, while the citation may have only been about the MRI scanner room door, the information that they provided, along with that citation, that gave us new supporting detail on some of the deficiencies that CMS had identified, but it also uncovered some new and alarming findings.

One of the sponsors of Invisible Force Podcast is CAIREreporting.org. That’s CAIRE spelled C A I R E. CAIREreporting.org is a confidential MRI adverse incident reporting system available to us the public as well as offering an enterprise solution to hospitals and imaging centers for secure and confidential reporting of MRI incidents, accidents, and near misses. If you have direct knowledge of an MRI accident that maybe it was swept under the rug. Or if you want information about how CAIRE could be set up as a private internal error reporting tool for your hospital or imaging center, CAIREreporting.org can help you with both of those. CAIRE has assembled a panel of international experts in MRI safety and accidents. Reports submitted either through the public website or through a private enterprise system. Get reviewed by their experts, who then deliver insights into the contributing causes of how the accidents or near miss events happened, and more importantly, steps that could prevent similar incidents in the future. For more information, please visit CAIREreporting.org. Again, that’s CAIRE spelled C A I R E.

When we got the Cal/OSHA document dump, it was a bit of a contradiction. They ultimately found only one element for which the hospital was cited, the safety situation created by leaving the MRI scanner room door open. But the more than 300 pages of documentation corroborated some CMS findings as well as some of the observer as well as some of the observations we made in our prior episode about MRI safety training and competency.

When we were going through the Cal/OSHA documents, a significant chunk of that novel-sized stack of paper, well that was printouts of the Kaiser Level 1 and Level 2 training materials. At first, honestly, there appeared to be an error, that they’d attached the same materials twice, but when we looked more closely, we realized that there was a difference. But the only difference between level one and level two training materials was the title slide. There appeared to be no practical difference between the content used to train their employees for level one versus level two training.

How can that be? MRI How can that be? Level two is supposed to be the level of MRI technologists and radiologists. You’re saying that there were no additional You’re saying that there was no additional information in the level two training as compared to the level one?

The title slide for the level two said that it covered more topics, but it didn’t. No. Level two did require a 20 question quiz after completing the 43-slide program. Level one didn’t require any retention questions. But apart from the retention questions, the content from the Cal/OSHA report for the two different programs was otherwise essentially identical.

Were there at least any competency checks to make sure that people could function at the level of MRI safety knowledge that the computer based learning module wanted to give them?

Well, that kind of depended on what department you worked for.

I’m not sure I understand what that means.

In the Cal/OSHA documents, there were not only the completion certificates for everyone involves level one or level two training, but for the radiology department employees, there were extensive employee competency checklists. Radiology department employees apparently had critical job skills, including MRI safety-related skills. Those were reviewed and signed off by both their immediate supervisor and then again signed off by the radiology director. For the MRI tech at the heart of this incident, there are pages and pages of competency reviews and sign-offs by that supervisor and the radiology director.

What about the ICU nurse? She didn’t work for the radiology department. If there was no practical difference between level one and level two training, and if the hospital’s radiology department was so rigorous on doing competency sign offs, surely someone was doing reviews and sign offs for nursing who were getting the level two safety MRI designation, right?

Well, while the Cal/OSHA documents have pages and pages of multi-level competency sign offs for the MRI technologist, there was no such documentation of any review or sign off of the nurse’s knowledge or understanding of the MRI safety designation that she’d obtained.

So the level two training was the same as the level one training, but with a few questions at the end and no requisite practical experience and no competency reviews and no sign off for the nurse?

Based on what was in the Cal/OSHA file, that appears to be the story.

In our last episode, we shared that the CMS investigation found that the hospital couldn’t really document MRI safety training for the people who were supposed to be in charge of MRI safety for the department. This Cal/OSHA revelation seems to suggest that even when the hospital had documentation of MRI safety training, the training booth the training both wasn’t specific to the expected skills and if you weren’t really in the radiology department, you might not be subject to the review or competency sign offs at all. I’m feeling more and more confident in our prior opinion that the MRI safety problems were systematic at Redwood City Hospital, and maybe even throughout the parent organization Kaiser. Since the Cal/OSHA report only cited the open door, they didn’t offer conclusions about the systemic problems, but we’re gonna suggest it here.

Thanks to this document dump, we also got a piece of information about why Kaiser Redwood City may have had a rose-colored perception of their MRI safety protections that they failed to see those systemic problems that you’re suggesting.

Okay. So now you’re talking about the physicist report, right?

Yes I am.

You may remember from our earlier episode how we shared with you that our initial searches for Redwood City Hospital turned up public relation pieces celebrating the hospital having been awarded an A grade for patient safety. Well the Cal/OSHA report turned up another document that might have contributed to the hospitals overestimating their MRI safety precautions.

Seemingly thrown in with the OSHA data dump was 15 to 20 pages of a physicist report on the MRI scanner at Redwood City Hospital. This report was dated five months -almost to the day- before the accident. All but one of those pages detailed the calibration and performance measurements of the MRI scanner. Geeky service engineer stuff. Now, despite the fact that Kaiser didn’t elect to get MRI specific accreditation for this MRI, the physicist who completed that evaluation, they filled out a copy of the ACRs, the American College of Radiology’s, MRI accreditation form called the MRI Safety Program Assessment Checklist.

Did that completed MRI safety scoring form alert the hospital to any of the many different problems that were identified by either CMS or Cal/OSHA?

In a word, no. That MRI safety program assessment checklist copied and pasted from the ACR’s MRI accreditation program, it indicated that the physicist who did the review passed every scored aspect of the hospital’s MRI safety program.

I’ve seen those checklists before and they’re awful. The form is named “MRI Safety Program Assessment Assessment Checklist,” and that sounds if it’s pretty comprehensive, but it’s nowhere near that. In my opinion, the completion of these forms amounts to compliance wallpaper designed to give the impression that safety has been evaluated in some meaningful way when what these checklists ask for are really the most superficial of all things.

What does this form typically look at and what does it miss?

There are only twenty-one checklist items on the whole thing. Of those, eighteen are questions whether or not there are policies on certain topics. ‘Is there a policy about add the MRI medical director?’ And we already know the hospital struggled with this. ‘Is there a policy on training?’ Also a problem area for the hospital as we heard earlier. ‘Is there a policy on quenching?’ And we know that didn’t go well either, and so on, so on and so on. So specific to this accident, the checklist doesn’t ask about what sort of training is provided or what the training content should cover. It doesn’t ask if the quench policies clearly articulate who has quench authority, under what circumstances should someone push the button, etc. The checklist form The checklist form only asks if a policy exists, not what’s in the policy or whether the policy’s content is appropriate.

You said twenty one checklist items, and eighteen of those are whether certain policy topics exist. What are the other three?

Well, two of the last three are also about policies. Are they reviewed on a regular basis? Though there’s no definition of what regular should be, and Redwood City hospitals hadn’t been reviewed for at least twenty six months prior. And secondly, are they available to the staff? The last checklist item asks if there’s “appropriate” signage and access control.

And what is considered appropriate for this checklist?

Well, that’s sort of the thing. There’s no indication, no identified objective standard. Now the ACR is the organization that developed and promoted the four-zone suite model that we’ve talked about quite a bit in prior episodes. But even though the ACR developed the four zone model, on the ACR’s MRI safety checklist, there’s nothing that describes what the minimum level of appropriate is, or that the expectation is even the ACR’s own four zone model.

Despite the problems at Redwood City Hospital with the MRMD appointment, the staff training, the quench policy, the MRI suite layout and zoning, their physicist gave them passing marks for everything when they filled out this form?

I think you’re making my point for me. If this form was truly an MRI safety program assessment checklist, as the name suggests, how would a facility with such widespread and pervasive problems get a perfect score on their review?

So here we have Redwood City Hospital, potentially counting on the perfect score from this MRI safety checklist as some sort of real indicator that they’re doing well. It almost seems as if they were taking an easy path towards MRI safety. Maybe they weren’t working to uncover the significant weaknesses that they had because they thought they were getting meaningful feedback that their MRI safety program was already strong.

Well, hindsight is 20 / 20. All these weaknesses become the subject of investigations when things go sideways, getting dragged out into the daylight in painful and embarrassing ways. But like we discussed in our last episode, each and every one of these weaknesses could have been identified ahead of time and fixed if they only took a bit of time to look for them.

Which is an excellent segue to questions about why these faulty conditions weren’t caught during State Department of Health licensing inspections. And whatever became of the California Department of Public Health’s report on this accident? We know CDPH was alerted within a week or so of this accident. We know because we did it. Months later, we’d digested both the CMS and OSHA reports, but where the hell was the CDPH report?

“Do you know what I’m holding in my hand?”

“No, sir.”

“It’s a document entitled MRI Safety Program Assessment Checklist for Redwood City Hospital’s MRI program.”

“Okay.”

“And do you know what it says?”

“No, sir.”

“It says that the MRI safety program passed review.”

“That’s a good thing, right?”

“Five months later, a nurse gets pinned between an MRI scanner and an ICU bed.”

“I… I don’t understand where you’re going with this.”

“What happened?”

“Sir? Well, the ICU bed got sucked…”

“I know that! I’m asking how we got a passing MRI safety assessment and then nearly killed somebody.”

In our next episode, we’ll get a response from the California Department of Public Health. Finally, after we were waiting for months and months for our requested copy of the state’s report on this accident. For this week’s show, our sources were the Cal/OSHA report, that CMS statement of deficiencies report, the Kaiser Permanente MRI safety policies, and per usual a whole bunch of confidential sources, both inside Kaiser and outside.

Our opening radio play, the one that dramatized what we imagine was the reaction of the Kaiser Bigwigs when they realized that perfect score they received on their MRI safety program assessment, wasn’t really a good indicator of the protections they had in place. Our voice actors for that dramatization were Brandon Grugle and Misha Stanton.

If you have any information about this accident or any other MRI accidents, please reach out to us. You can do that through our website, InvisibleForcePodcast.com. There you can find episodes and show notes. Also, you can leave us a voicemail with information about this incident or any others on our tip line. Area code 631-MRI-tips. That number again is 631-MRI-tips or 631-674-8477.

And if you work in hospital safety, state health regulation, CMS, healthcare policy, or radiology management, and you have any questions about MRI safety or professionally approved standards or the standard of care, we want to hear from you. Lastly, we’d like to ask you to like and share our podcast with your friends and colleagues and coworkers with your help, we’ll unravel the mystery of what happened, and with a little bit of luck, we can help make sure that accidents like this don’t ever occur again.