As the Long Island neighbors said, “that should never happen,” and, “someone should be responsible.” So who had responsibilities to make sure that Nassau Open MRI was being run safely, and protecting the public from fatal MRI accidents? Between the feds, the State of New York, and Nassau County, *somebody* had MRI safety rules… right?
In this episode we take close looks at the MRI safety provisions and requirements of the different organizations, from the FDA and CMS, to national accreditation organizations like Joint Commission, to the State of New York, all the way down to the municipal requirements of Westbury, NY, and the staff at Nassau Open MRI.
What we’ll discover is that when it comes to MRI safety minimum rules, there effectively aren’t any. MRI is, from a patient safety standpoint, the ‘wild west’ with almost nothing assuring the safety of MRI patients or technologists.
Show Notes:
2013 NYSDOH Document Identifying Absence of MRI Safety Standards
Leaked Security Camera Footage
Newscasts 1 and 2 From Which We Used Commentary
Transcript:
“That’s insane, that should never happen, you know? It has to be someone’s responsibility.”
“I think that they should have had better precautions, like how that even happened, how do you even get to that point.”
“That really makes me upset, because that should never happen.”
Hello, and welcome back to the Invisible Force Podcast. This podcast series is built around exploring MRI incidents and accidents that often get described incorrectly in your local news or online news stories as freak accidents. Our entire first season is dedicated to an accident that you’ve heard about in the news and in previous episodes of this podcast. A man who died in an MRI accident out on Long Island, New York just a few months ago in July of 2025. In this accident, Mr. Keith McAllister died after he got pulled into an MRI scanner by a 20-pound chain that was around his neck. This happened at a place called Nassau Open MRI. Let’s take just a brief moment to reintroduce you to the co-hosts for our podcast.
I’m John Posh, an MRI technologist, educator, longtime advocate for MRI safety practices. I’m also currently faculty at two universities and teach MRI safety multiple times per year.
I’m Toby Gilk. I’m a certified MRI safety officer, certified MRI safety expert. I’m an MRI facility architect, safety consultant, and co-author of a new book, The Technologist’s MRI Safety Handbook. O
ur first four episodes are what we’re calling act one. These were all about the specific events of the accident, what happened, who responded, and what happened immediately after. This episode begins act two, where we dive deeper into the various key players in this mystery. Over the next several episodes, we’ll be looking closer at the people and organizations that played a role in this event, or ought to have played a role in keeping it from happening. This episode begins act two, with us trying to answer the question that the people of Nassau County were asking in our intro. How could this happen? Isn’t there some organization or government standard out there to protect MRI patients, enforcing some minimum MRI safety standards?
So this episode might be better titled Alphabet Soup, because of all the acronymed organizations we’re going to be introducing it to. We’ll try and make sure we give full names, but some of them are just such a mouthful that will probably revert to using their acronyms pretty quickly.
Let’s start from the top and work our way down. Let’s start at the United States federal government. And our first stop is going to be the US Food and Drug Administration, or FDA. Now, while it’s not in their name, Food and Drug Administration also regulates medical devices including MRI scanners. Well, it would be fairer to say they kind of regulate MRI scanners. You see, the FDA regulates whether the devices perform as designed. If the manufacturer says, Our product produces 42 bajillion gigaparsecs of toe jam, then the FDA’s regulatory job is to make sure that the device from that manufacturer performs as well as the manufacturer claims it does. Generally, what the FDA looks at are things like, are the pictures as good as promised? And if the machine says it’s outputting a specific amount of RF energy, is it actually putting out that amount of RF energy?
In one respect, the FDA, at least with respect to MRI, has been extremely successful. The number of times someone is injured because of an MRI device machine error is extremely low. Mr. McAllister wasn’t pulled into the MRI tube because the machine wasn’t functioning properly, but rather because MRI machines have hugely powerful magnetic fields. They do police the performance of the MRI device itself, but what’s the FDA’s role in the safety of how people use the MRI machines and the safety at the hospital or imaging center? Anyone?
Within the FDA, there’s a specialty department called Center for Devices and Radiologic Health, or CDRH. Now, CDRH oversees x-rays and CT scanners and PET scanners and ultrasound and more. And for all of these, the FDA doesn’t regulate anything beyond whether or not the machine does what the manufacturer says they’re supposed to do. Well, that’s true for everything except mammography. In 1992, the United States Congress passed the Mammography Quality and Standards Act, better known by its acronym, MQSA. Now, MQSA gave the FDA authority over quality and safety at the point of care in a hospital or in an imaging center, but only for mammography. So it literally took an act of Congress, but with MQSA, the FDA now regulates the safety of your mother or sister or daughter getting a mammogram. But getting an MRI, even a breast MRI, the FDA doesn’t have any jurisdiction over the quality or safety of the point of care. So for this incident and really almost any MRI incidents, the FDA is pretty much worthless as a regulatory body when we’re talking about patient safety.
Now, the FDA does require reporting of regulated medical devices when it’s relating to injury or deaths, and you can actually go on to the FDA’s website and search for reported incidents. And many people, myself and my co-host included, thought that these reports were to advance the safety of the devices to the public. And I guess in a roundabout way they do. But the real reason the FDA collects these accident reports goes back to the FDA’s job of making sure that medical device manufacturers are honest about how their equipment performs. If the scan device over time starts failing below the stated performance minimums, then the FDA can come back and slap the manufacturer on the wrist. This is what’s called post-market surveillance, and it’s primarily about living up to the manufacturer’s specifications, and not necessarily about uncovering previously unrealized risks associated with how these products are used.
Now, the other big federal government entity that could potentially play a role is the Center for Medicare and Medicaid Services, or CMS. And please don’t ask me why there are two M’s in the name, but only one M in the acronym, one of life’s great mysteries. The overwhelming majority of hospitals and imaging centers in the United States participate in the payment programs that CMS administers, Medicare and Medicaid. CMS is the biggest government insurer. If you got an MRI from one of these CMS participating hospitals or imaging centers, the provider would send an invoice for the care that they gave you. They would send that invoice to CMS, and they would pay for the MRI exam in a manner similar to how your private insurance company does. Because CMS is, financially speaking, an 800-pound gorilla in the healthcare space, they get to make some of their own rules. They get to require that providers meet certain, what are called, conditions of participation or conditions for coverage. Those are essentially prerequisites or minimums to participate. Otherwise, you don’t get paid. Now, these conditions include a lot of really big hand-waving aspirational language like, ensure the safety or must be free from hazards. But while the CMS language is chock full of good intentions, it’s actually woefully short on actual specifics.
But as it turns out, Nassau Open MRI, where Keith Macalester died, is one of the few that didn’t actually participate in CMS reimbursement programs. So therefore, the CMS conditions of safety didn’t even apply to them. If you’ve ever worked around health care, you might also be familiar with enterprise-level accrediting organizations like either the Joint Commission, which accredits hospitals, or modality-level accreditation organizations like the American College of Radiology’s MRI accreditation program, which can be required for outpatient imaging facilities. And some hospitals get these also just to show off a bit. These various programs have different levels of minimum MRI safety standards from ones that what we’d call have C-level safety standards down to accreditation organizations that barely even mention MRI. Being accredited by one or more of these organizations can be pricey, so facilities tend to only do what’s required, and CMS generally requires that providers be accredited. But, as we mentioned before, since Nassau Open MRI didn’t participate in Medicare or Medicaid, there was nothing that compelled them to get accredited. So it appears that they didn’t.
We’re going to circle back to the state of New York, sort of our mid-level player, in the second half of this episode, because, quite frankly, they require a little extra time. For the moment, we’re going to drop down past the state, down to Nassau County, where the accident actually occurred, and look at their role in this. In previous episodes, you heard us talk about how MRI suites are supposed to be separated into sort of a free access part, and then, as you get closer to the actual MRI scanner, a secure access part. There are actually building codes that require facilities get built this way, but you’ll remember that this particular MRI scanner was in a permanently parked semi-trailer, and not in a building, per se. Many cities, states, counties require healthcare design codes for hospitals, but even if the same patient is going to get the same MRI scan on the same MRI scanner, if it’s in an outpatient clinic, many local jurisdictions say, codes, we don’t need no stinking codes, at least for the design of outpatient imaging centers. And if the MRI is in a semi-trailer, then the parts of the building that really are the trailer and not a real building, those often escape the minimum requirements that would exist if the same MRI was inside a bricks and mortar building instead of a trailer. Even if Nassau County did require a locked door with their building codes for an MRI in a semi-trailer, if the facility didn’t keep the door locked, there’s really nothing that the city or county building inspector or codes enforcement office could really do about it. Code inspectors almost never spot check a building for compliance for those sorts of things.
Now, after Mr. McAllister died, his death was investigated by the Nassau County Police’s Homicide Unit. It’s important to note that being investigated by the Homicide Unit doesn’t mean that they were treating the death as a murder, but any unusual death gets investigated by this particular unit, so there you have it. The case was purportedly also referred to the Nassau County District Attorney, who declined to file any criminal charges against either the company, Nassau Open MRI, or any of the individuals in the incident. We’ll really touch more on this in the next episode, so make sure you’re already subscribed.
Very shortly after the accident, we heard from confidential sources that police and fire responders were trading a video of the accident among themselves. It may sound weird to you, but it’s not unusual for first responders to trade pictures or video trophies of their more bizarre calls. In fact, at the time, our source said it was a question of when, and not if, that video would find its way onto the internet. A few weeks later, a one-minute video clip was leaked online. The first instance that we were aware of was a post on Reddit, which was taken down very quickly. But by that time, it was already in the wild and that video soon started appearing on Instagram and TikTok and YouTube and elsewhere. We’ve even posted a link to it on the show notes for several episodes on our website, invisibleforcepodcast.com.
Since we knew that Nassau County Police had the video and probably had considerably more than the one-minute clip that was circulating, we thought we’d ask them for it. The state of New York has a Freedom of Information Law, FOIL, that allows the public to request copies of government documents. We’ve requested information on the 911 call, the dispatch discussions, body cameras, incident reports and collected evidence, including the security camera video. So far, Nassau County has rejected all of our FOIL requests because the emergency service response documents require a notarized release from an individual involved in the incident itself.
So, we know all this evidence exists. The closed-circuit video, more than the one minute’s worth, and presumably, footage from a bunch of different cameras. We know that there’s the incident reports, there’s probably body camera footage, incident photos, but because we’ve, at least so far, been unable to get a notarized release from what the FOIL law requires as an involved person, it all remains out of reach, which means, at least for the time being, we’re only solving this mystery with more help from you and a good bit of shoe leather.
The season one sponsor of the Invisible Force podcast is cairereporting.org. Now that’s CAIRE spelled C-A-I-R-E. cairereporting.org is a confidential MRI adverse incident reporting system available to 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 miss. If you have direct knowledge of an MRI incident 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 your imaging center, cairereporting.org can help you with both of those. CAIRE has assembled a panel of international experts in MRI safety and MRI accidents, and reports submitted either through the public website or through an enterprise system get reviewed by experts who then deliver insights into the contributing causes of how accidents and near misses 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.
In the first half of the program, we gave you a rundown of pretty much every organization who you might think has some sort of duty or responsibility to keep people safe in a healthcare facility. Well, everyone except for the state of New York. Frankly, we were able to rule out the entire federal government and Nassau County based on those organizations’ own jurisdictional limitations, as well as the fact that the MRI provider, Nassau Open MRI, appears to not have been a participant in either of the reimbursement programs or the standards organizations at the time of the incident. But the state of New York and their duties to keep people safe, that’s a little bit more involved. The second half of this episode is really dedicated to the Empire State and what the state could have done to protect Mr. McAllister.
We’ll start with the organization that we think should have had a role in keeping MRI care safe, the New York State Department of Health. Although it turns out that the New York State Department of Health doesn’t actually have any standards on MRI safety. Picture a big hospital in your mind. Now, imagine that you have a giant laser cannon, a Star Wars Death Star type of thing, but smaller. You point it at that imaginary hospital building and you core a hole that’s about 30 feet wide right through the center of that building. Afterwards, you see a 10-story hospital complete in every respect, except for the piece of sky that you now see right through the glowing edged hole in the middle of the building where that MRI used to be. That’s a visual metaphor. A hospital with a giant hole in it where the MRI suite used to be is a pretty accurate representation of the scope of the New York State Department of Health’s regulations of hospitals. They regulate every aspect of a hospital except MRI.
Now, we’d love to tell you that this was just an oversight, that everyone in the New York State Department of Health was just going about their daily lives, assuming that there were MRI safety standards, especially because a young boy named Michael Colombini died in an MRI accident in New York in 2001, and everybody knew about that one. But no, this wasn’t the Department of Health operating in blissful ignorance. How do we know this? Because they documented the fact that they knew that they didn’t regulate MRI, even when, as partners of CMS, they’re supposed to have state safety standards for what are called advanced modalities, things like CAT scan, PET scans and MRIs.
In 2013, in the wake of a new federal law that defined these advanced diagnostic imaging modalities, the New York State Department of Health conducted an evaluation of their state licensure requirements with respect to how much or, in this case, how little. They agreed with the definitions of advanced diagnostic imaging. That report reads, Currently, there is no statutory authority in New York State to regulate MRI, only ionizing radiation, x-ray and nuclear medicine. Let that sink in for just a second. The state where the most famous or infamous fatal MRI accident in the United States, at least the one prior to last summer, the state where that happened doesn’t even define, much less have, safety standards for MRI.
So we figured, perhaps naively, that the 2025 McAllister MRI death would have stirred up a swarm of new activity and discussion around MRI safety in the state of New York. In most state departments of health, the people that tend to know the most about radiology are often found within offices whose names are things like Radiation Protection or Radiation Health. In New York, this office is named the Bureau of Environmental and Radiation Protection, with one of the worst acronyms imaginable, BERP. So we picked up the phone and called them because surely they were aware of the accident and surely they’d be a party to the furious discussions we imagined would be happening within the state of New York. Well, we were half right.
Yeah, BERP was very much aware of the accident. In fact, thanks to a few connections, I actually found myself on a conference call with the BERP director, Charles Burns, and the associate director, Sarah Hime, as well as one or two of the group’s medical physicists. They were very clear with me that they were aware of the incident, but BERP’s legal mandate was exclusive to ionizing radiation, the kind of radiation that comes from X-rays and CT machines. They made it clear that they had no authority over MRI. I did get the sense that they were quite concerned about this incident and the fact that it was likely very preventable. I asked about their involvement, BERP’s involvement in the discussions about what actions the state would be taking in response. And they said that if those conversations were happening, they were happening without BERP. When I asked who would know what was happening within the Department of Health, they pointed me to the Associate Commissioner in the Department of Health’s Office of Government and External Affairs. Her name was Ms. Alissa DeRosa. She gave us some of the most encouraging news that we had heard to date. She said in an email to me, Unfortunately, we are unable to provide information at this time due to ongoing investigations. And I thought, oh my God, there is an investigation underway.
But from all our digging, it seems pretty clear that the Department of Health had never been given jurisdiction over MRI and MRI safety. Did the fact that there was a fatality unlock some different authority? We certainly didn’t want to look a gift horse in the mouth, because we were very excited that they said there was an investigation, any investigation underway. But we thought that if we better understood the authority under which the investigation was happening, we might be able to better understand who would be talking about future improvements. The authority for the investigation might itself give us some useful insights. So, we followed up and got some deflecting responses. We’re looking into all these questions and should have some additional information for you soon. We’re still having active internal discussions on this, but should have an answer for you next week. Well, soon and next week came and went, and Mr. Rosa became less and less responsive to our requests for promised information.
Eventually, we kind of got pawned off. Ms. Nicole Katz, an Assistant Commissioner for the Office of Government and External Affairs, presumably Ms. DeRosa’s supervisor, responded with a final clarification about the authority for that investigation that was underway. She wrote, When it was noted that the issue was under investigation, this was in reference to our internal review to provide you with an eventual response. This was not an investigation performed by an oversight or regulatory entity. So New York State Department of Health was stonewalling and gaslighting us with fake confidentiality over a fake investigation that wasn’t actually happening. At this point, the Office of Government and External Affairs told us that any further communication would need to be requested through not their office, but through the New York State Department of Health Press Office. And we were eventually put in touch with a representative of the Press Office, Cadence Aquaviva, in early December.
Again, we asked about whether or not there were on-going conversations within the State Department of Health about MRI safety. After a couple of initial clarifications of who we were and why we were asking these questions, we got another round of radio silence. We asked for updates and again got politely worded delay messages. “I’ll check on this for you today”, “still working on this for you,” or “I’m close to finalizing response and had hoped to be able to send it to you later today.” Ultimately, weeks later, we got “we appreciate the information that you’ve shared with us from your perspective as a subject matter expert who works in the field. The department takes patient and provider safety seriously. We are closely monitoring the developments related to this event but have no further comment at this time.” In other words, a complete and total brush off.
Let’s pull back from the details of our story in the Department of Health’s pretend investigation and talk about what state Departments of Health’s jobs typically are. Now, this is going to vary state by state, but almost always they regulate licensed health care facilities, which means hospitals and depending on the state you’re in, may also include outpatient imaging facilities. They regulate these and licensed health care providers like doctors and nurses. Now, licensure is just a way of imposing some minimum quality and safety standards on either the institution that is the hospital or some of the specifically trained health care workers who work for them. Radiation protection offices within Departments of Health typically have regulatory authority over devices like CT scanners, regardless of whether they’re in a hospital that requires a license or, as is the case in New York, even if it’s in outpatient providers, that the state doesn’t require a license for at the provider level.
To better illustrate this condition in New York state, just a few months before the McAllister death, in a different outpatient facility in upstate New York, it was reported that a mom was accompanying her young child for an MRI. With some striking parallels to the McAllister story, it appears that that mother was permitted into the MRI scanner room with her kid, despite having never been properly screened. We assume that mom was a law enforcement officer, but for whatever reason, she was packing heat. When mom got close enough to the scanner, purportedly the magnet pulled the gun from its holster, and the gun flew into the MRI. Thankfully, it was reported that the gun didn’t go off, which is a real possibility. Several years ago, an MRI patient was shot and wounded with his own gun at a VA hospital in Indianapolis, and just a few years ago in Brazil, the son-in-law of the patient was also in the MRI scan room and was shot when the MRI pulled the gun from its holster. The guy in Brazil wound up dying from his injuries. Now, despite the fact that these types of injuries have a track record of hurting and killing people, the New York State Department of Health said that they couldn’t investigate because they only have licensure jurisdiction over hospitals and no device jurisdiction over MRI scanners.
In a parallel track, before we had figured out that we had exhausted all of our options within the Department of Health and ran smack dab into their stonewall, we figured that maybe there’d be some interest, or at least concern, on the part of the political class. So we reached out to the scheduling office for the New York State Governor’s Office, not to speak with Governor Hochul herself directly, but to see if we could connect with an aide or a policy advisor who worked with the governor’s office on health related issues. After a couple of months, we got a “Governor Regretfully Declines” form letter.
We had also reached out to the chairs of each of the New York State Senate and Assembly Health Committees, requesting an opportunity to speak with a policy aide about the accident and MRI safety standards, or really the absence of them. Eventually, we were connected with a policy aide for Assemblymember Amy Paulin’s office and had a conversation about how this state’s infamous MRI fatality body count had just gone up and how these sorts of accidents were both anticipatable and preventable. A few weeks later, we got word back that Assemblyman Paulin was not interested.
If all of this sounds like we’ve spent months in our interactions with the state of New York, as if we were mice running around a giant maze, looking for that expected block of cheese, only to encounter dead-end after dead-end, yeah, that’s pretty much what this has felt like. Well, with one very recent and very notable exception, we started out trying to connect with an aid to New York State Senate Health Committee Chair, Senator Gustavo Rivera, at the end of August of last year. We had a very long Groundhog Day experience. We called, we e-mailed, we were promised e-mails or phone calls from policy aids to the Senator, but those promises to schedule a phone call or get e-mails from a policy aid who wanted to talk to us, that never actually happened. Well, not until just a few days ago.
It would appear that our unrelenting persistence paid off. I mean, it took over six months, but just two days ago, we got a call from Claire Yost. Ms. Yost’s job title is legislative fellow for the Senate Health Committee Chair, New York State Senator Gustavo Rivera. We talked for about a half hour, and she expressed shock and horror in all the right places that the New York State Department of Health was functionally ignoring MRI safety precautions and said that they didn’t have legal jurisdiction to oversee MRI safety or investigate MRI safety accidents, even the fatal Long Island accident. From our side, that conversation included how, as a profession, radiology knows how MRI accidents and injuries occur and how they’re almost always foreseeable. We also discussed how there are existing standards of care preventions that we know can be remarkably effective at preventing MRI injuries and accidents. It’s just that nobody actually requires those protections.
We talked through how we thought that New York really ought to have an MRI regulatory structure that parallels what they do for ionizing radiation, making sure that there were some basic MRI safety standards in place, whether the scanner was in a physician’s office or an outpatient imaging center or in a hospital. Now, Ms. Yost indicated that she was going to be sending our request up the chain within Senator Rivera’s policy staff, and we were promised follow-ups. Although, New York State legislative session is about to begin and policy staff lives were about to get really hectic because of the legislative session. Now, while that conversation did go very well, we don’t for one second think that this one conversation, no matter how promising it was, means that positive change is some sort of done deal. We know that we’re going to have to stay on top of it.
To recap, with respect to point-of-care MRI safety in general and the McAllister incident in particular, the feds, both the FDA and CMS, are like the hear-no-evil, see-no-evil, speak-no-evil monkeys. When we dropped down to the county level, we’ve been effectively locked out of the public record information because of the county’s requirement for a notarized letter from an involved person and so far we haven’t been able to get that. New York State’s Department of Health has given us a huge run around. BERP, the one department within the Department of Health that was receptive to us, was legally limited from being able to help us. When they pointed us to their policy office, we got gas lit and stonewalled and ultimately pawned off to a media office that said they were done talking with us.
We got immediately dismissed by the governor’s office even without a conversation. We did get a conversation with a policy aide from the State Assembly Health Committee Chair’s Office, but after that conversation, we heard that the assembly member wasn’t interested in MRI safety. The one candle in the darkness that has been New York State government was only just lit, and that was an encouraging initial conversation with someone from the Senate Health Committee Chair, Gustavo Rivera’s office. We’re going to do everything we can to protect and grow the light from this one little source, and in subsequent episodes, we’ll be sharing you what, if anything, is actually changing for MRI safety in New York.
“That’s insane. That should never happen. You know, it has to be someone’s responsibility. “
“I think that they should have had better precautions, like how that even happened, how do you even get to that point. That really make me upset because that should never happen.”
Next episode, we’re going to switch our focus from the would-be regulatory players back to the family of Keith McAllister and his now widow, Mrs. Adrienne Jones McAllister. So please make sure you’re 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 leaked security camera footage of the accident, New York State’s FOIL law and Nassau County’s responses to our requests, the 2013 New York State Department of Health memo that identified their lack of MRI standards, conversations with the leadership from the New York Bureau of Environmental and Radiation Protection, or BERP, a few hundred emails with the representatives of the Office of Government and External Affairs, the Press Office, the New York Governor’s Office, and the offices of the chairs of both the New York State Senate and Assembly Health Committees as well as some confidential sources.
Our intro montage was assembled from local news coverage of the time.
And if you have any information about this incident or any MRI incidents, please reach out to us either through our website, invisibleforcepodcast.com. And on the website, you will find episodes and show notes and a tip line contact option there. In addition to the website, you can leave us a voicemail with information about this incident at area code 631-MRI-TIPS. The number again is 631-MRI-TIPS or 631-674-8477.
aWe’d also ask you to like and share our podcast with your friends and colleagues. With your help, we will unravel the mystery of what happened. And together, with a little bit of luck, we’ll help make sure that accidents like this don’t ever occur again.
