Description:
The MRI accident nearly killed a nurse. But in the days afterward, it seemed as if almost nobody wanted to talk about it.
When the Invisible Force began investigating the 2023 MRI accident at Redwood City Hospital, the story was strangely absent from local news—even though photographs of the ICU bed stuck to the MRI scanner were circulating through professional radiology communities.
Hospital employees and other sources described a climate of silence. Then we discovered something even more troubling: a previous MRI projectile accident had apparently occurred at the same hospital—a ventilator pulled into the MRI scanner. What had been learned from that earlier warning? We couldn’t find out.
So we turned to California’s Department of Public Health.
And that’s when the investigation took an unexpected turn…
The state health department appeared not to know about the nurse who had nearly been killed. Our call became the first indication that the accident had occurred at a hospital under its jurisdiction. The complaint was subsequently forwarded to the Centers for Medicare & Medicaid Services (CMS)—and CMS didn’t simply pass it back to the state to handle.
CMS initially classified the incident as “Immediate Jeopardy.”
What does that mean for a hospital? What happens when CMS determines that an MRI safety failure represents an immediate threat to life or safety? And what does a hospital have to do to avoid losing its Medicare and Medicaid reimbursement?
In this episode, The Invisible Force follows the investigation from the hospital’s silence to federal regulatory scrutiny—and begins uncovering the MRI safety failures, corrective actions, and unanswered questions that would lead us toward separate CMS, OSHA, and California investigations.
This is the story of what happened after the MRI accident—and how much more there was to uncover.
Show Notes:
CMS-2567 “Statement of Deficiencies | Plan of Correction” Report for Redwood City Hospital (8.4 MB)
Transcript:
“California Department of Public Health, how can I help you?”
“Good morning. I know it just happened, but I’m calling to put my name on a list to request a copy of the CDPH investigation report for the MRI accident, the one where the nurse was almost killed by the ICU bed. I’d like a copy of the report as soon as it becomes available. “
“I’m sorry, what accident?”
“You know, the one that just happened last week with the nurse pinned by the ICU bed.”
“I’m sorry, you’re asking about an accident where you almost killed a nurse?”
“Yes, the one that happened last week with the nurse pinned against the MRI by the ICU bed. I’m calling to put my name on the list to get a copy of the state’s investigation report as soon as it’s available.”
“Maybe my supervisor knows about this. Hold, please.”
Wait, are you saying that the people at the Department of Health didn’t know about the accident? How could they not?
That’s exactly what we wanted to find out.
“So, I understand that you’re asking about some MRI accident you say just happened?”
“Yes, an ICU nurse who got pinned between a bed and an MRI scanner and was badly injured. That got reported to CDPH, right?”
“And when was this supposed to have happened?”
“Last week. Wait, was this not reported to you?”
“Hold on a minute. I think I should be transferring you to my supervisor.”
“But, but, but…”
“What’s this about an MRI accident you say happened?”
Welcome to the Invisible Force. This is an investigative documentary podcast about MRI accidents, patient safety failures, health care mysteries, and some of the hidden risks of modern medicine.
In this series, we’re doing a deep dive into an MRI accident in which a nurse was very 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.
Before we pick up our story from our prior episode, this is a great time to reintroduce you to the co-hosts for our podcast.
I’m John Posh, an MRI technologist, MRI educator, and longtime advocate for MRI safety practices. I’m Chief Academic Officer and MRI Program Director at one university, and adjunct MRI faculty at a second university.
And I’m Toby Gilk, certified MRSO and certified MRSE, MRI facility architect, safety consultant, and a co-author of a new MRI safety textbook, The Technologist’s MRI Safety Handbook.
In our previous episode, we recreated the sequence of events of this accident. The MRI patient from the emergency room who never showed up, the blown up schedule, the newly hired ICU nurse, and the bureaucratic workflows that left blind spots in essential safety protections.
This episode picks up from where we left off. You’ll remember the MRI tech, covered in the ICU nurse’s blood, standing at the doorway of the MRI suite watching the care team wheel the horribly injured nurse towards the emergency department. Her emotional blankness shocked away momentarily, jerked back into the here and now when she heard the MRI scanner quench itself in response to the mortal wound that it suffered with the ICU bed jammed into the bore. That’s where we start this episode of the story.
We picked this up in the days immediately following the accident, asking the questions, who knew and when did they know it? If you ever walked into a room where two people were having a knockdown drag out argument just seconds before, but as soon as you enter, they both turn really quiet, there’s a distinct uneasy feeling that hangs in the air, that unnatural silence is what descended on Redwood City Hospital and Kaiser Permanente in the days and weeks after the accident, waiting for the inevitable other shoe to drop, unleashing a new round of chaos as soon as the story broke in the local news media.
The accident occurred on a Thursday, and over that following weekend, several brave and generous people had posted in online radiology communities, not only the pictures of the ICU bed caught by the MRI scanner, but also the name of the hospital where it occurred. Surely, now that it was out in these radiology communities, it was about to go public in a big way. In these cloistered online communities, we knew what had gone terribly wrong, as well as where it had happened. John on the East Coast and me in the Midwest. By that Monday morning, we had the major outlines of that accident. But as far as the story had spread in the radiology online communities, the people for whom Redwood City Hospital was their community hospital, there was nothing in any of the Bay Area news outlets. No local TV news, nothing in the newspapers, nothing even in the hyper local online communities like Bay Area subreddits. Silence.
Prior to this, Redwood City Hospital hadn’t been on either of our radars, so one of the first things we did was search for the accident online and see what we could learn. Instead of finding accounts of the accident, a couple of the most recent news stories about the hospital, ironically, celebrated recent “A grades” in patient safety they’d received. For a short while, it felt like we were being gaslit, as if we were being told that the thing that we knew had happened hadn’t actually happened. Honestly, it was a bit alternate reality feeling for a little while.
On the Monday or Tuesday of the week following the accident, I called Redwood City Hospital asking for the radiology department. When I told the person who answered the phone that I was calling about the accident, it seemed as if they immediately assumed that I was someone from within Kaiser. After all, four or five days after the accident, there was still nothing in the local press. It must have appeared that there was no way an outside person would have been able to trace this back to the hospital. Not yet, anyway. The person who I spoke with mentioned something about the internal accident analysis being underway, but you’ll have to talk with the radiology director for any more information. You’ll appreciate that she’s been in constant meetings over the past few days, so you’ll have to leave her a voicemail. I did. That message was never returned.
At the same time, we were trying to learn more about the condition of the ICU nurse. People close to Redwood City Hospital who were willing to message us shared what they’d been hearing, and it wasn’t looking good. Depending on the version of the story, the nurse had a broken femur, the thigh bone, which requires tremendous amount of force to break, a crushed pelvis, or some combination of both. This was in addition to penetrating injuries from having been impaled by the bed. Some early rumors had even suggested that she died from her injuries, but thankfully those turned out to be wrong. The stories mostly shared that she was in ICU, but we weren’t able to corroborate any of this. A colleague in San Francisco asked around with some of the people who worked at Stanford Hospital to try and verify the story that we’d heard that the nurse was sent from Redwood City to there, but that yielded neither a yes, she’s here, or a no, she’s not here.
So we wound up going back to asking questions of the people in the Kaiser Organization. After a few more days of trying, I actually managed to catch the Director of Radiology from Redwood City Hospital on the phone. Like that earlier call that had been answered by a department receptionist, at first the Radiology Director seemed to think that I had to be internal to Kaiser because even a week and a half later, there still wasn’t even a whisper of this story in the local media. But after only a couple of questions, asking about the condition of the nurse, and my genuine surprise at the news that the ICU patient was essentially uninjured, the Director quickly pivoted and asked if I was with Kaiser Risk Management. When I said no, that I was investigating this accident independently, our very short conversation was terminated abruptly. She closed with a statement, something along the lines of, nobody here will talk with you if they want to keep their jobs.
Did you feel like she was saying that as a threat to her department employees, if you tried to talk with them, that she would fire anyone she’s heard that you might have talked with?
I took it a little differently. I took it as a sign that everyone at Redwood City Hospital had been warned that talking about the accident outside of official channels could put their jobs at risk. And that’s an interpretation. We couldn’t establish who had given those instructions.
Phrases like, “if they find out I’ve talked with you, I’ll lose my job,” were shared with us repeatedly from both direct and indirect Kaiser contacts. The pattern we were seeing suggested to us that Kaiser intended to do everything they could to keep the story of this MRI accident tightly contained, and that included warning employees, contractors, and even vendors. People shared fears that even getting discovered that we had reached out to them put them at risk of losing their jobs, their contracts, or their businesses with Kaiser Permanente. While that may have worked as an intimidation tactic for many, some people who we contacted were definitely afraid of losing their jobs and asked us not to reach out to them again. There were others who were slightly more brave, who felt that this story deserved to be told and to hell with the risks.
Not long after hearing of the ICU bed accident, we learned that this wasn’t even the first major projectile accident that had occurred at this hospital. A picture was shared with us of an MRI scanner room by appearances, the exact same one with the ICU bed photos, and a patient ventilator, a device that breathes for critically ill patients when they can’t do it for themselves. That ventilator was jammed into the bore of the MRI scanner. We don’t know if that vent had been connected to a patient, breathing for that patient, when it got sucked into the MRI scanner. Trust us, that has happened before. The pictured vent, that accident purportedly occurred in the first year or so after the new hospital building opened. What happened at Redwood City Hospital in response to that prior vent accident? We don’t know. But near-miss events like this can be huge red flag indicators of systemic problems.
Both of us literally have libraries of pictures of things stuck in or on MRI scanners, ventilators, wheelchairs, IV poles, beds, rolling carts. Depending on the size of the object, it’s possible that something goes flying into the MRI scanner and does little more than some like cosmetic damage. But it’s also essential to recognize that every time something goes flying into an MRI scanner, it is by definition something that puts people at risk of death or serious injury. Now, just because we didn’t have any information that someone was injured by that earlier ventilator accident at Redwood City Hospital should not be taken as indication that it wasn’t a serious accident. To the people at that hospital, that ventilator should have been a flashing red light indicating a substantial weakness in their MRI safety policies or practices.
To the best of our knowledge, that prior vent accident wasn’t reported anywhere. Not to state license authorities, not to the accreditation organizations, possibly not even up the corporate ladder through Kaiser risk or compliance offices. Beyond the picture, we’re not able to identify any other details of that prior vent accident. We can’t identify specifically when it happened or how it happened or whether or not anyone was hurt. More importantly, we don’t know what might have been done in an attempt to strengthen the MRI safety practices at Redwood City Hospital to make subsequent MRI projectile accidents less likely in the future.
So as you heard in the last episode, this incident happens at a facility with a cramped and difficult MRI suite layout. And now we know this was at a hospital with a track record of at least one prior large projectile accident. Kaiser and Redwood City Hospital closed ranks swiftly, offering implicit or explicit threats to anyone who might talk with us. We needed another way in, which is when we put in calls to the California Department of Public Health, and that next call wound up launching an entirely new mystery.
The sponsor of the Invisible Force podcast is CAIREreporting.org. 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 enterprise solutions 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 on 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 the 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 might prevent similar accidents in the future. For more information, please visit CAIREreporting.org. That’s CAIRE, spelled C-A-I-R-E.
Within the first several days after we learned of the accident, it became exceptionally clear to us that official channels of communication with either the hospital, Redwood City, or the parent company Kaiser Permanente weren’t going to give us anything useful. We’d begun to develop a number of unofficial channels into the Kaiser 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. Kaiser was keeping information strictly siloed. Even people responsible for MRI safety at other Kaiser hospitals in California hadn’t been told about the Redwood City accident. It was time to supplement what we were learning with a formal report.
Despite how impressive, in a scary way, Kaiser’s ability to keep this story out of the press was, we knew that there was at least one party who they would have told. Because Redwood City Hospital is licensed by the California Department of Public Health, or CDPH, and because accidents like this are required to be reported to the license authorities, and because most state records are open to the public, we wanted to be the first to get in line to get a copy of that eventual CDPH report. Now, we know the speed at which state governments generally move. So when we called CDPH about a week after the accident, we weren’t actually expecting any information from them about the accident. Our entire aim was to find out how to get our names on the list to get a copy of the report when it was finalized, presumably several months later.
California law requires hospitals to report injury accidents within five days. So we were sure we were going to be doing the equivalent of grabbing a number ticket at a crowded deli. Securing our place in line for this eventual state report. Our opening audio play, however, with Toby getting passed from person to person to person at the regional CDPH office, which jurisdiction over Redwood City Hospital is pretty much exactly what happened.
Yeah, I may have been a little slow on the uptake, but by the second person, I started figuring out that there seemed to have been no report made by the hospital to CDPH. And while nobody, not even the third person I talked with, said so explicitly, by the time that call was finished, I was certain that this was the first time anybody at the California Department of Public Health had even heard that a nurse was very nearly killed at a hospital they licensed. Unknowingly and completely unintentionally, I was the person who alerted CDPH to this preventable and grievous accident.
As a side note, we later heard from a confidential source that Kaiser pled ignorance of the mandatory reporting requirement, stating that they thought they were only required to report patient injuries.
We didn’t know this at the time, but when a safety complaint about a Medicare participating hospital lands at the State Department of Health, they forward a copy of the details to CMS, the Centers for Medicare & Medicaid Services. For most complaints that the states forward along to them, CMS takes a pass. They leave it to the states to handle. This, however, was not one of those times. CMS actively took up the complaint, and quickly we learned why. CMS initially classified this incident as representing immediate jeopardy.
That term immediate jeopardy sounds ominous, but what does it mean?
So, there are two distinct levels of severity in CMS investigations of hospital. An incident can just be alarming, what’s called a condition level deficiency. Now, that triggers an investigation and a report, or a situation can be deemed to have put someone in immediate jeopardy, when there’s an immediate threat to the life or safety of people inside the hospital. The reason that designation is so potent is because it’s an explicit threat to kick the provider out of all future CMS reimbursements if the immediate threatening condition isn’t fixed now, and the source problem that underlies it if that’s not corrected within 23 days. Now, we don’t know specifically for Redwood City Hospital, but nationally around 30% of hospital revenue comes from CMS reimbursements. So, the threat of losing 30% of your revenue within a few weeks is of the absolute highest concern to a hospital. CMS looked at the initial facts of this accident, and they designated it as an immediate jeopardy or an IJ condition.
Our first thought was that a swarm of feds with CMS emblazoned on Navy blue raid jackets would fly in to investigate. Turns out that’s wrong. We learned that CMS doesn’t have a stable full of federal accident investigators that it sends from state to state, hospital to hospital, looking in to reported accidents. Instead, they have partnering arrangements with various states where they can temporarily deputize the state’s Department of Health investigators to conduct an investigation on behalf of CMS. So, when CMS took an interest in this accident, it was actually CDPH personnel who were going to do the legwork for them. When we learned about this, we figured this was a smart way to kill tubers with one stone, collecting the information for both the federal and state investigations simultaneously.
We had enough of a window into the Kaiser Permanente actions that we know that the IJ determination represented an existential threat to the finances of Redwood City Hospital. And there was almost nothing that they wouldn’t do to resolve this. We expect that there were regional or maybe even national Kaiser bigwigs, some of whom who may never have actually heard of Redwood City Hospital before that week, sitting in on meetings and making promises of corrections to the CMS deputized CDPH employees. Now, the hospital executives were wrestling with two huge intertwined problems. How do we continue to keep this incident out of the press? And how do we respond to CMS so that the hospital isn’t financially crippled in just a few weeks?
For Redwood City Hospital, the fact that the accident effectively killed their MRI scanner pretty much removed the immediate part of immediate jeopardy. So when the state’s inspectors first showed up on behalf of CMS, they downgraded it from an IJ investigation to a condition level investigation. A less immediate financial threat to Kaiser, but still a huge sort of Damocles hanging over their heads. They had a little bit more breathing room, but they were still going to need to move quickly to satisfy CMS in order to protect their ability to get paid for care to CMS patients.
In CMS investigations, Statement of Deficiencies Plan of Corrections documents do exactly what the name suggests. On one side, CMS writes down all the ways in which the hospital failed to meet the minimum conditions of participation. And over the next few weeks, the hospital has to fill in the Plan of Corrections column on the other side of the document, detailing how they have responded or how they will respond to each of the identified deficiencies. Upon receiving the hospital’s Plan of Correction, CMS can accept the provided plan, reject the plan, kicking the provider out of CMS reimbursement right away, or they can send it back to the provider with a saying, We’d like to see you do more, kind of notes, and include an extension of up to a couple of months to resubmit.
We were informed that CMS initially rejected the Redwood City Hospital Plan of Corrections, indicating that the first round of corrections that the hospital offered was less than CMS wanted to see. We imagine the hospital executives sweating bullets. They desperately needed to get this situation resolved to CMS satisfaction because the alternative was unthinkable. Despite not being satisfied with Redwood City Hospital’s first plan, giving them a second shot with extensions suggests that CMS must have felt that serious progress was being made. So they pushed back the deadline for the nuclear option of kicking them out of Medicare and Medicaid reimbursement programs and gave the hospital up to another couple of months to strengthen their original response and get it back to them.
The hospital’s second submitted Plan of Corrections for MRI was signed off by the Kaiser Representative on May 16th, almost three months after the accident. This revision was the one ultimately accepted by CMS.
What did the final plan include? What did they have to do in response to the CMS investigations?
The final accepted plan included a laundry list of corrective items, evaluation of their MRI safety policies and training, MRI facility design review, requiring MRI safety training for all MRI staff, naming of— Anyway, hold on.
You’re telling me they didn’t require MRI safety training for all MRI staff before this event?
That wasn’t their policy beforehand, no. And you might think that that violates some sort of minimum licensure or accreditation requirements, but it doesn’t. It raised the question for us, are the standards CMS holds you to after something bad has happened more stringent than the standards they’ll hold you to in order to prevent the bad thing from happening? Are they more punitive than preventative? But we’re getting ahead of ourselves a bit.
Well, with the acceptance of the revised plan of corrections, the threat of being kicked out of CMS reimbursement programs, Kaiser must have been deeply relieved. I imagine that for months this whole process was going on, Kaiser executives were routinely breathing into paper bags to help stem their hyperventilation. The threat of CMS not accepting the second plan of corrections had consequences that must have seemed unthinkable. When CMS ultimately accepted the revised plan, it must have taken loads of weight off someone’s shoulders. But as far as Redwood City Hospital was concerned, CMS was satisfied, right?
Yeah, I mean, they eventually got there.
So that was it then, it was done?
Well, CMS was done, yes, but investigations, no, not even close. Because the person badly injured was the nurse and employee, it meant that another federal agency also got to investigate, OSHA. Redwood City Hospital had cleared one hurdle, CMS, but there was a completely separate workplace safety investigation that had kicked off that same spring while the hospital was working to please CMS. That OSHA investigation was collecting troves of documents from the hospital, far more than CMS, digging deep into areas that the CMS investigation had largely glossed over, and that OSHA investigation uncovered faults and weaknesses that the CMS investigation missed entirely.
Later that summer, with the CMS report in hand, and while we were anxiously awaiting the release of the completed OSHA report, we remembered that the original phone call, the one in the reconstruction that we opened the show with, the one where we asked to get our names put on the list to get a copy of the state’s report, we’d never actually received a copy of the CDPH’s report. What we thought was just a simple bureaucratic oversight, however, turned into an odyssey of sorts that continues from three years ago when this happened all the way to today.
“California Department of Public Health, how can I help you?”
“Good morning. I know it just happened, but I’m calling to put my name on a list to request a copy of the CDPH investigation report for the MRI accident, the one where the nurse was almost killed by the ICU bed. I’d like a copy of the report as soon as it becomes available. “
“I’m sorry, what accident?”
“You know, the one that just happened last week with the nurse pinned by the ICU bed.”
“I’m sorry, you’re asking about an accident where you almost killed a nurse?”
“Yes, the one that happened last week with the nurse pinned against the MRI by the ICU bed. I’m calling to put my name on the list to get a copy of the state’s investigation report as soon as it’s available.”
“Maybe my supervisor knows about this. Hold, please.”
“So, I understand that you’re asking about some MRI accident you say just happened?”
“Yes, an ICU nurse who got pinned between a bed and an MRI scanner and was badly injured. That got reported to CDPH, right?”
“And when was this supposed to have happened?”
“Last week. Wait, was this not reported to you?”
“Hold on a minute. I think I should be transferring you to my supervisor.”
“But, but, but…”
“What’s this about an MRI accident you say happened?”
In our next episode, we’ll look specifically into what we learned from the CMS investigation while we were waiting for that OSHA report to be issued, as well as the incredible difficulty we had in getting our hands on the CDPH state report.
For this week’s show, our sources were multiple different interactions with California Department of Public Health, CMS Statement of Deficiencies report, and a whole bunch of confidential sources, both from within Kaiser and outside. If you’ve been one of our sources, please know that we take your need for confidentiality very seriously, and we will protect you from being identified.
Our opening radio play, which recreated my initial call to the California Department of Public Health, trying to get a copy of the state’s investigation report, our voice actors for that dramatization were Brandon Grugle, Julia Shafini, and Misha Stanton.
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, show notes, and a tip line, which are always available through the website. Also, you can leave us a voicemail with information about this accident or any MRI accident at 631-MRI-TIPS. The number again is 631-MRI-TIPS or 631-674-8477.
If you work in hospital safety, state regulation, CMS, healthcare policy, or MRI, and something in the story doesn’t make sense to you, we want to hear from you. Lastly, we ask if you would please like and share our podcast with your friends, colleagues, and coworkers. With your help, we’ll unravel the mystery of what happened here, and with a little luck, we’ll help make sure that accidents like this don’t ever occur again.
