Description:
An ICU bed dragged into an MRI scanner. A nurse crushed against the machine. Written safety policies, hospital accreditation, and layers of oversight—and still, a catastrophic injury.

What has to change before it happens again?

In the Season 3 finale of Invisible Force, John Posh and Tobias Gilk bring together what their investigation uncovered about the 2023 MRI accident at Kaiser Permanente’s Redwood City Hospital—and what remains hidden.

An employee told investigators that Regional Risk Management said the accident was not reportable to California’s Department of Public Health. Government reports exposed failures in safety practices and responsibilities. Questions about the state’s response remain unanswered, and we still lack a verified update on the injured nurse’s recovery.

Those gaps matter. But the evidence already offers lessons that other hospitals cannot afford to ignore.

We examine what it takes to make MRI safety work under pressure: clear responsibility, workflows built for real patients, practiced emergency responses, and follow-through that tests whether a fix actually protects anyone.

The season ends. The need for accountability and prevention does not.

Plus, a preview of Season 4: a patient burned during an MRI—and a danger that doesn’t depend on an object flying toward the magnet.

Find episodes, show notes, and our confidential tip form at InvisibleForcePodcast.com.

Show Notes:
CCR Tit. 22, § 70974 – Adverse Events-Policies and Procedures
HSC § 1279.1 – Injury Adverse Event Reporting Requirements
Joint Commission’s Explicit MRI Safety Standards

Transcript:
The records we’ve obtained in this investigation don’t tell us much about the nurse after the accident, even though, in some ways, she’s the most important character in this story. We imagine what may have happened with her immediately after the accident.

“Wait, where am I?”

“It’s okay, it’s okay. You’re still in shock. Just breathe.”

“I was bringing the bed into the MRI room and then, and then…”

“You got caught in between and crushed.”

“What happened? Where are you taking me?”

“Don’t worry, you’re getting an express trip straight to surgery.

“Surgery? What happened to me?”

Hello and welcome to our wrap up of our third series of the Invisible Force podcast. Invisible Force is an investigative documentary podcast about MRI accidents, patient safety failures, healthcare mysteries, and some of the hidden risks of modern medicine. This particular season has been 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 2023 in California, and the ripples from this accident are still with us today.

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

Now, this is the part of the intro where normally you’d be introduced to my good friend and co-host, John Posh. Unfortunately, John is feeling under the weather, he has lost his voice, and he can’t record. So for this episode, you’re stuck with just me.

Let’s start with a quick recap of the instigating accident. An ICU bed was brought into the room with an MRI scanner, and that bed was turned into a magnet-homing missile. It flew at the scanner. The ICU nurse, who was driving the bed, wound up trapped between it and the MRI scanner, caught in a magnetic vice. The decision to quench the magnet to kill the MRI’s magnetic field and release the nurse wasn’t made immediately, presuming the need for some external approvals. Instead, the nurse was torn free and rushed off for badly needed medical attention.

Over the last several episodes, we shared with you what others have shared with us. We shared our shock at the lack of contemporary news about the accident in the press, the results of both the CMS and the Cal/OSHA investigations that occurred months later, what appears to be a complete lack of any state level hospital licensing investigation on the part of the California Department of Public Health or CDPH, and some alarming revelations of safety issues that CDPH apparently feels are outside of its purview, and some very ambiguous accreditation standards. Now, for this episode, we’re going to try and put a bow on it and provide you with a reflection of where we are in the telling of this story, as well as what’s next.

You might think in this era of cell phone cameras and social media that it’s almost impossible to keep accidents like this out of the public’s eye. And that’s somewhat true for this accident. We didn’t become aware of it because it was originally splashed across CNN or even Bay Area local news reports. No, an anonymous account posted a photo from this accident, no other details, on a radiology subreddit. And then they promptly deleted their account shortly after. That picture got shared across radiology and MRI social media forums. And in the days after, details started getting added to the picture. The where, the when, and the how of that accident.

According to the records of one of the investigators for CMS, in an interview of the hospital employees, one of them stated that the accident had been shared up to the Regional Risk Management Office. And that that office advised that the accident was not reportable to the California Department of Public Health. In contravention of the state’s mandatory reporting requirements in CCR Section 70737, and perhaps even HSC Section 1279.1, if you’re playing at home. So when we called CDPH to inquire about the accident a week or so after it happened, we were surprised that they were surprised to be hearing about this accident from us.

The first official report that we received was the one from CMS, or Center for Medicare and Medicaid Services. Because Redwood City Hospital bills CMS for care delivered to Medicare and Medicaid patients, the hospital has to comply with what CMS calls its conditions of participation. CMS maintains the right to independently verify compliance with their quality and safety standards. When they learned about the accident, it was treated so seriously that had Redwood City Hospital not made some serious improvements, the hospital would have been kicked out of the federal reimbursement programs. The CMS report detailed a number of failures, from safety governance all the way down to the failure to follow site policies to keep the MRI scanner room door closed and locked.

The Cal/OSHA report only officially cited the issue of keeping the MRI room door closed and locked, but the materials that came with that report, that illuminated a number of other serious weaknesses, including faulty MRI safety training and competency structures, a rose-colored prior safety scorecard that appeared to not have looked at the underlying conditions, documented policies that appeared to have been very different from how things were practiced on a day-to-day basis. Cal/OSHA assessed the hospital a fine of $18,000, which is probably the tiniest fraction of what the annual revenue losses would have been had CMS kicked them out of the federal reimbursement programs.

The hospital’s accreditation organization, the Joint Commission, also looked into the accident. However, because TJC is a private accreditation organization, virtually all of the information about what they did or what they didn’t do in response to this accident is confidential. We know that they looked into it, that at least they’ve said that much. But whether they identified any problems or required any remedial action from the hospital, that will probably never know. As frustrating as it may be to not know what the Joint Commission did, we know that they do acknowledge their jurisdiction and that they did something under that jurisdiction.

What we later learned from CDPH is that they assert that they have no jurisdiction over MRI and MRI safety in a hospital. There appears to have been no state hospital license investigation and no administrative action or penalty from CDPH as a result of the accident that nearly got the hospital booted from CMS payment programs. We say that it appears that the state took no action with regard to the state license obligations because CDPH is denying our requests for documents using what California calls the investigatory file exemption to disclosing public records. Curiously, CDPH is simultaneously asserting that they have no state-licensed jurisdiction over MRI safety. So we’re not sure whether the investigation that they’re not disclosing documents from is an investigation into the accident, or it may be an internal-to-the-department investigation about whether or not they can investigate the accident.

When we’ve asked how can you be conducting a state-licensing investigation into an MRI accident when you assert that you have no state-licensed jurisdiction over MRI at all, the department asserts other exemptions to keep from providing us documents. To date, we still don’t know if CDPH conducted any sort of state-level investigation of this accident. But we do know that they’re withholding records from us that might include their discussions of whether they could have or should have looked into this or taken any action.

If you’ve been listening closely to the series, as well as our earlier ones, you may have noticed something is missing from this particular story, at least so far. The Lawyers. Almost a year to the day after the accident, attorneys representing the ICU nurse filed personal injury lawsuits, seeking punitive damage with the Superior Court of California in San Mateo County, the county that includes Redwood City Hospital. Court records will often include depositions and affidavits and preliminary decisions by the judge, various exhibits. Despite the fact that this lawsuit is now coming up on three years since it was filed, most of the documents filed to date are discussions about the multiple permutations of the hospital’s legal name that appeared in the initial complaint, questions about representation for a separate worker’s compensation claim, and various court scheduling matters. Nothing so far that’s really helpful in explaining the story.

Earlier last year, I identified the attorneys from the original lawsuit court filings. I reached out to them. Initially, they were very interested to talk with me. But a number of months ago, they went quiet. They stopped responding to e-mails and phone messages. We were hoping to, at the very least, get information on the nurses condition to be able to share with you. But we’ve been unsuccessful at that.

If we were writing an unabridged history of this accident, which to be clear, we’re not, those missing pieces would be a big problem. But what we’re after is identifying the ways that hospitals, licensing authorities, accreditation organizations, and regulatory bodies can make MRI services safer. And we’ve already gotten plenty from this story to be able to make several observations and recommendations.

The sponsor for the third season of the 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 all of us, the public, as well as offering an enterprise-level solution to hospitals and imaging centers for secure, confidential reporting of MRI incidents, accidents, and near misses. If you have direct knowledge of an MRI accident that may have been 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 an assembled panel of international experts in MRI safety and accidents. Reports submitted either through the public website or through an enterprise system get reviewed by their experts, who then deliver insights into the contributing causes of how 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. That’s Care spelled C-A-I-R-E.

Before the break, we summarized the information that we had gotten and the pieces we haven’t, at least we haven’t gotten them yet. But as compelling as these stories are by themselves, for us, the real value is in identifying how similar accidents can be prevented going forward. With that in mind, let’s start zoomed all the way in to the MRI suite where the Redwood City Hospital accident happened. The thing that both the CMS and the Cal/OSHA reports hammered on was the fact that the hospital’s policies said to keep the MRI scanner room door closed, and it wasn’t. And depending on who the investigators talked with, it sounds as though that was a recurring issue.

Reading between the lines, it sounded to us like the door being open and the MRI scanner table being undocked in the MRI room on the day of our accident, that those were adapted responses to both schedule pressures and an otherwise poor design layout of the MRI suite. To be clear, I’m not suggesting that it’s okay to disregard policies simply because things got busy. But I’ve seen sites where the written policies or the physical layouts or both are fair weather versions. They don’t anticipate additional time pressures or patient handling complications. Plenty of sites have policies that focus on the most frequent types of patients, generally low-acuity outpatients. But when we have complex inpatients, the policies or site designs can sometimes seem like they’re coming apart.

In our previous episode, we acknowledged that we didn’t identify any facility design lapses in terms of complying with either the California Building Code or the accreditation requirements from Joint Commission. This sets us up for what’s likely to be a recurring observation. From an MRI safety perspective, the regulatory or accreditation minimums, they often aren’t minimum enough to protect MRI patients and workers. The code and accreditation-compliant design, it appeared to directly contribute to the sequence of events in this accident. The training policies which ostensibly got the approval during the MRI safety program assessment review performed by the hospital’s physicist, that review and approval, that clearly left a lot on the table. The mandatory screening review for the ICU patient, the nurse and the nurse’s aid, those things didn’t happen. Providers need to make sure that they’re looking at how they want to build their processes and workflows, and then make sure that the policies, the training and even the bricks and mortar of the building follows their intended workflow, not the other way around.

And taking that fair weather remark a step further, we also need to make sure that more than our policies and buildings anticipate the emergencies, we need to make sure that the people are trained for it. It appeared, from all the report narratives, as though their regular safety training at Redwood City didn’t stick for at least the nurse and the nurse’s aid, not in the way that we would expect with the failure to screen the patient and taking the ICU bed into the MRI room. The tech appears to have remembered their training and was at least considering quenching the magnet. Either there was inappropriate bureaucracy surrounding the quench button pushing authority, or there was a horrible misunderstanding about that bureaucracy, which had the same net effect, keeping the nurse trapped longer.

John and I, we’ve talked about it a number of times. We’ve talked about the importance of having an emergency policy and knowing what to do in that emergency are two very different things. When John ran MRI facilities, he had his staff do emergency drills. As a consultant, when I’ve done facility safety evaluations, one of the things that often pops up is that they’ve never stress tested their safety policies, or at least not in a long time. I and John were both enthusiastic supporters of making sure that all MRI employees, even the ones who work overnights and weekends and holidays, have regularly recurring emergency drills. It’s one thing to read the words of the policy, and it’s entirely different thing to throw yourself in between an onrushing code team and the door to the MRI scanner room. This also means making sure that for each person or each role, the MRI safety duties and responsibilities are made crystal clear.

So, for this accident, the text confusion about the quench authority and the hospital and radiology groups confusion over who held clinical responsibility for MRI safety, unfortunately, those are great examples of how an individual’s understanding of their responsibility can break down at all levels, directly at the point of care, all the way up to the managerial and oversight levels. Who sets training and competency standards for MRI safety? Who sets policy for clinical decision-making? Who manages review and clearance of complicated MRI patients? Who defines or evaluates emergency response practices? This isn’t simply stuff rolls downhill and the practical responsibilities of all of this lands at the feet of the MRI technologists. Not that techs don’t have some very important responsibilities because absolutely they do, but sites also need to make sure that the duties for modality supervisors, on-call radiologists, department managers and radiology chiefs or designated MRMDs, that each have their MRI safety roles and responsibilities very clearly articulated.

This may feel like it’s all just about Redwood City and this one accident, but this is just one illustration of how normal protections can break down and let catastrophic accidents slip through. Throughout this season and the other two seasons too, we’ve highlighted some fairly universal concerns. Inadequate training or competency verification relative to MRI safety, ambiguous MRI safety roles or responsibilities, problematic MRI suite layouts or access controls, lack of clear safety governance structures, incomplete MRI safety policies, lack of emergency preparation. Particularly since specific concerns have been what we’ll call frequent flyers in our first three seasons, I’d say that every MRI provider should be routinely looking at each of these concerns and providing an honest assessment of how strong or weak they are in each of these. I want to make sure that we’re not laying the responsibility for all of this only at the feet of hospitals and imaging centers.

There’s also the issue of governance over the providers. And that means organizations like CMS, like your state Department of Health, like your accreditation organization. When we look at the set of circumstances that led to a nurse being pinned against an MRI scanner, gored by parts of the ICU bed, and we look at the explicit minimum MRI safety requirements of all of the organizations that are supposed to be assuring safety, it’s difficult to see how their specific criteria would have prevented this accident. We’ve had almost identical observations at the end of season one, looking at the fatal accident at Nasau Open MRI, and at the end of season two, looking at the OG MRI accident at Westchester Medical Center.

So if you’re involved in providing MRI care at a hospital or an imaging center, here are a few critical questions to ask yourself.

• Do we have clear lines of MRI safety authority? For example, do we have an identified MRMD or MRSO? And are those individuals trained and credentialed for those specific safety roles?
• Are our MRI safety policy documents up to date with the standard of care? Does what we actually do at the point of care, does that agree with what our policies say we should be doing?
• Are we operating exclusively as fair weather providers? Or have we actually practiced what we would do in an emergent situation?

Now, if you’re coming at this from the role of a regulator, a license authority or an accreditation organization, have you looked at:

• how MRI accidents occur?
• And where process, practice and governance breaks down to allow these incidents to happen?
• Do you have specific concrete standards that should interrupt the causes of MRI accidents?
• And if you don’t have your own standards, do you at least identify or invoke professionally approved standards from outside your organization?

MRI clinical care and safety is advancing so quickly that none of these, whether at the level of an individual facility or regulators, none of these should be seen as set it and forget it. We need to establish feedback loops to ask if the conditions have changed and if what our practices and standards were last year, do they do at least a good job of protecting us this year? If you’re not circling back, if you’re not appointing someone to observe and critique your site’s code drills, someone reviewing the contemporary literature and best practices, someone making sure that you have MRI safety specific governance structures with MRSOs and MRMDs minimally, you could find yourself in a situation similar to that of the people of Redwood City Hospital, where they appear to have believed that they were on a solid MRI safety footing, and it was only after the accident investigation illuminated specific governance, policy management, and operational weaknesses, that the scope of the problems were brought to the attention of the hospital.

There’s more than enough of the gestural sorts of stuff out in the world, right? “We follow all applicable standards of care.” “Our policies are meant to assure the highest level of care.” “Our accreditation promises the highest level of quality and patient safety.” We’ve had that sort of vague and aspirational regulation, accreditation, and policy statements for decades, and it isn’t stopping injury accidents in MRI. There’s an incredible body of MRI safety best practices, and it’s long past time that they became integral with the individual site policies and practices, as well as our license and reimbursement minimum requirements.

As an epilogue of sorts, we still don’t know about the nurse’s condition or her recovery. It was shared with us, but we have no way to validate it, that upon returning from medical leave for her injuries, the nurse was going to be subject to disciplinary action, possibly even termination, for violating the site policies on MRI safety screening and bringing magnetic objects into the MRI scanner room. The last we heard, the MRI technologist, and again, we’ve not been able to verify this, was that she continued to be an employee of Kaiser. We know from a number of sources that the Redwood City Hospital Director of Radiology was moved to a different role shortly after this accident. We don’t know if it was a demotion, but the director was moved out of that role at Redwood City. According to the summaries of interviews that were conducted with the Redwood City Radiology Department folks, both the chief of radiology and two co-chiefs at different times in the interviews were identified as having clinical responsibility for MRI safety as the site’s MRMDs. We never learned if those individuals, the chief of radiology or the co-chiefs, ever demonstrated any MRI safety or MRMD role-specific training.

And as we mentioned in an earlier episode, we can’t offer any firsthand knowledge of whether the hazards identified in the public reports have been effectively managed by the changes that were made at Redwood City Hospital or elsewhere throughout the Kaiser Permanente enterprise. We hope that the lessons that were there for the learning from this costly accident have been applied, improving the safety of MRI services at Redwood City Hospital going forward.

“Wait, where am I?”

“It’s okay, it’s okay. You’re still in shock. Just breathe.”

“I was bringing the bed into the MRI room and then, and then.”

“You got caught in between and crushed.”

“What happened? Where are you taking me?”

“Don’t worry, you’re getting an express trip straight to surgery.”

“Surgery? What happened to me?”

In our next episode, we’re going to launch into our fourth series. This next series centers around a hospital patient who was badly burned in MRI because of a dangerous interaction between something that came with them from the ICU and the MRI scanner itself. Make sure you’ve subscribed to the Invisible Force podcast to get the next episode as soon as it drops.

For this week’s show, our sources were the various accident reports, the Joint Commission and our interactions with them, the California Department of Public Health, and piles of documents from public records requests, as well as some confidential sources.

Our introductory dramatization of the nurse being wheeled back to surgery that was voiced by Brandon Grugle and Julia Schifini.

If you have any information about this accident or any MRI accidents, please reach out to us through our website invisibleforcepodcast.com. There you’ll find episodes and show notes. Also, you can leave us a voicemail with information about this accident or any MRI accidents at area code 631-MRI-TIPS. That number again is 631-MRI-TIPS or 631-674-8477.

If you work in hospital safety, state health regulation, CMS, health care policy, or other places in MRI, and something in our stories just don’t make sense to you, we’d like to hear from you. Lastly, we ask you to like and share our podcast with your friends and colleagues and coworkers. With your help, we’ll unravel mysteries of what happened in these accidents and with a little bit of luck, we’ll help make sure that accidents like this don’t ever occur again.