Description:
What does hospital accreditation tell us about MRI safety—and what happens when a serious accident exposes weaknesses that earlier surveys missed?

In 2023, an ICU bed was pulled into an MRI scanner at Kaiser Permanente’s Redwood City Hospital, crushing a nurse. The hospital held Joint Commission accreditation. A subsequent federal investigation documented 13 pages of deficiencies. How did those safety problems go undetected?

In Season 3, Episode 6 of Invisible Force, MRI safety experts John Posh and Tobias Gilk examine whether hospital accreditation can fill the oversight gap left by California’s asserted lack of jurisdiction over MRI safety. They compare Joint Commission requirements with federal expectations and professional safety guidance, exploring MRI suite design, staff training, emergency quench policies, and equipment safety.

They also ask a question with consequences far beyond one hospital: When patients or staff are injured at an accredited facility, how does the accreditor use that evidence to strengthen its standards?

Drawing on investigative records and direct exchanges with Joint Commission representatives, this episode examines the limits of accreditation—and the accountability questions that confidential investigations leave unanswered.

Explore episodes, show notes, and our confidential tip contact at https://InvisibleForcePodcast.com. Have information about an MRI accident? Leave a voicemail at 631-674-8477 (631-MRI-TIPS).

Follow Invisible Force to continue the investigation.

Show Notes:
CMS-2567 “Statement of Deficiencies | Plan of Correction” Report for Redwood City Hospital (8.4 MB)
Joint Commission’s 2015 Diagnostic Imaging Standards

Transcript:
“And what about the accreditation?

“Sir?

“Redwood City Hospital held accreditation from… from…

“Joint Commission, sir.

“Right. And they assert that one of the goals of their accreditation is zero harm.

“Well, yes.

“And the hospital was surveyed by Joint Commission?

“A few times, at least, sir.

“And did any of those surveys identify MRI safety deficiencies?

“Not that I’m aware of, sir. And when the CMS report came out, it had 13 pages of deficiencies listed?

“It did.

“And enterprise accreditation is supposed to be a demonstration that the hospital met the CMS requirements, right?

“I think I see where you’re going with this.

“If our accreditation is supposed to be a demonstration of CMS compliance with an aim of zero harm and our MRI service apparently cleared multiple surveys, how did we wind up with 13 pages of deficiencies after an accident that nearly killed a nurse?

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 2023 in California, and the ripples from this accident are still with us today. Before we pick up our story from the prior episode, this is a great time to reintroduce you to our co-hosts for the podcast.

I’m John Posh. I’m an MRI technologist, MRI educator, and longtime advocate for MRI safety practices. I’m also the chief academic officer at one university, adjunct faculty at another, and have been teaching MRI safety for over 30 years.

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

This third series started with our recreation of the accident, the immediate aftermath, and eerie absence of any inkling of this story in the press, the CMS report on the accident, the Cal/OSHA citation and documentation, the runaround that we received from CDPH only to eventually learn that CDPH asserts, without providing any support, that they can’t oversee MRI safety, leaving a huge MRI sized hole in the state’s jurisdiction. When we closed our previous episode, we left you with the question of whether accreditation might be plugging the hole left in the state-licensed jurisdiction. First, a very quick summary of the role accreditation serves and what it promises to do for health care organizations that get it. As we’ve mentioned in earlier episodes, a hospital or imaging center in the United States that wants to get reimbursed for care provided to Medicare, has to be either reviewed through their state’s Department of Health or accredited. Nearly all opt to have it done by separate accrediting organizations or AOs. If you’re a hospital and you get privately accredited, you have to have what’s called enterprise level accreditation, which accredits the hospital from the helipad on the roof to the mechanical equipment in the basement and everything in between. If you’re an outpatient imaging center, you have to have modality level accreditation, which accredits specific scanners individually.

Each of the AOs has to minimally include the specific elements that CMS identifies as essential. However, when it comes specifically to MRI and MRI safety, CMS really doesn’t spell out any minimum specific criteria. There are some broad brush stroke CMS radiology safety aims that can be generally applied to MRI. Now, each of the AOs largely gets to create whatever MRI safety minimum standards they want to. Most of them have few, if any, meaningful MRI safety minimum criteria, which is a bit odd because all of them market themselves to the hospitals and imaging centers as offering an assurance of safety by preventing foreseeable types of harm through their standards.

But what if they did? What would it look like if the accreditation organizations were serious about managing MRI risks? First, it would involve recognizing the types of MRI accidents that occur over and over again and drilling down to the contributing causes of these accidents such as magnetic projectile accidents. Next, build a set of minimum standards that interrupt the causes of accidents. For our magnetic projectile example, the minimum standards might be built around identifying objects with projectile risk or training staff who work in MRI or making sure that the facility had sufficient non-magnetic materials or strict forms of access control. Lastly, when accidents do occur, there should be a robust investigation into how that accident still happened and what strengthening could make similar accidents harder to happen in the future.

So, how does this compare when we look specifically at what happened at Redwood City Hospital? The nurse and the nurse’s aide brought the ICU patient straight from the shared radiology corridor into the anteroom just outside the MRI scanner room. The industry standard, the ACR four-zone, would put two spaces between the public areas, in this case, that shared radiology corridor, and the MRI scanner room. Redwood City had only one. The hospital’s accreditation organization, the Joint Commission, despite the fact that they defer to the ACR for MRI safety practices, Joint Commission doesn’t require their accredited sites to have the two intervening spaces. They only require one.

California doesn’t use the same hospital design code that almost all of the rest of the US does, the FGI code. The FGI requires the use of the ACR four-zone model. California Building Code, on the other hand, is more in line with what the Joint Commission describes, a minimum of one space between the public and the MRI scanner room. So while the physical layout at Redwood City Hospital appears to have met the minimum criteria for the state building code and the hospital’s accreditation, the Joint Commission, it really didn’t meet the wider safety standard.

Now let’s do the same for the safety training standard. What are Joint Commission’s minimum MRI safety training standards? Of the four hospital staffers who were there at the time of the accident, the MRI tech, the ICU nurse, the tech aide and the nurse’s aide, only one of them would be required by the Joint Commission in what used to be called Joint Commission or TJC’s diagnostic imaging standards. Only one of them would be required to have any MRI safety training, only the MRI tech. The Joint Commission’s standards only describes a training requirement for the MR system operator, and then only describes training that addresses seven broad topical areas.

So, per Joint Commission standards, the ICU nurse, the nurse’s aide, and even the MRI technologist aide weren’t required to have any MRI safety training.

Not explicitly, no. Joint Commission does have boilerplate safety practices appropriate to the working environment, sorts of broad aims. But where they spell out who minimally needs MRI safety specific training? No, only the tech. Nor does the MRI section require radiology directors or radiologists or MRMDs to have any MRI safety training for the service that they have direct responsibility for.

But while we may take issue with the quality of the staff’s MRI safety training, the documents we got from Cal/OSHA show that at least the four Redwood City Hospital employees who were there for the accident did get some MRI safety training.

Such as it was, yeah.

Well, clearly there were some issues with the quality of the training and whether the hospital verified retention. And it’s worth repeating that when asked, the hospital couldn’t or wouldn’t produce any documentation about the radiologist’s MRI safety training. But the four staffers in the MRI suite at the time reportedly all got some form of MRI safety training.

Which suggests that maybe the minimum training standards should have some sort of sign-off or competency review. In this story, the MRI technologist appeared to be the only one who was capable of acting on her MRI safety training. And she had repeated episodes of that training and reviews and sign-offs. Yes, she didn’t push the quench button when I think I would have. But it turns out that she did call for authorization. She just didn’t get that authorization. And yes, I too found the site’s documented quench policy ambiguous. But we should probably note that the Joint Commission doesn’t have any specific training requirements for what the hospital’s MRI quench policy should say.

So let’s bring these all back to Redwood City. Do we think that a requirement for the ACR four-zone, having a screening space separate from the anteroom, could have prevented this accident?

As a 100% guarantee that the accident wouldn’t have happened? No, I don’t think that we could say that. But remember, the ICU patient and nurse were in that anteroom, the Zone III space, with the MRI room door propped open. Had there been a Zone II screening area, there would have been an entire additional zone closed off between the patient and the MRI scanner room. It would have made it less likely that the nurse had an unobstructed pathway.

And didn’t the layout of the Redwood City anteroom or Zone III area make it such that they couldn’t get the undockable table out of the MRI room until the ICU patient had arrived?

Yes, the four-zone model alone wouldn’t automatically fix that problem. But there were layout and design issues in addition to the missing Zone II space.

And what about the training? Joint Commission only requires training for the MRI tech. But the tech aidee, the ICU nurse, and the nurse’s aide also had MRI safety training. Isn’t that a demonstration that the hospital was going above and beyond?

Above the Joint Commission minimums? Yes. But Joint Commission’s accreditation minimums are not only below the standard of care defining document, they’re actually below what CMS requires.

What do you mean?

CMS actually says that all persons permitted to enter a radiology area should receive appropriate safety training. So the fact that Redwood City trained the nurse and the nurse’s aide may have been above what Joint Commission said they needed to do, but it’s actually just the minimum of what CMS says they should have done.

A lot of good that training did.

Good point. Which brings me back to the idea that people with responsibility for this service ought to have MRI safety training too. Maybe then they would have had a better perspective on where the program weaknesses were.

We ended the last episode with the question of whether the accreditation would be effective at filling the gap left by CDPH when they abdicated jurisdiction over MRI. I think what we’re learning is that while some of the AOs might have MRI standards, they’re not an effective substitute for a state licensure standard.

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Before the break, we sought to answer the question of whether the accreditation organizations were doing the MRI safety monitoring job that we argued the state of California ought to be doing. We looked specifically at a few of the MRI safety accreditation criteria of Redwood City Hospital’s AO, the Joint Commission. We felt that, no, their MRI safety standards weren’t terribly effective, certainly not enough to stand in for the role that a state license authority would normally fill. But let’s look at the other side of things. Let’s put forward an argument on behalf of the Joint Commission and all of the other AOs.

First, we need to acknowledge that the hospital accreditation standards are intended to apply across a wide range of providers, from tiny rural critical access hospitals to urban medical academic centers. In many instances, standards can’t be too prescriptive because of the significant variation in size and variability. We also need to recognize another practical limitation. Joint Commission only actively surveys a hospital for compliance for a few days once every three years, unless there’s a complaint.

But more than 90 percent of the MRI scanners in the United States are accredited either by enterprise level accreditation like the Joint Commission, or by MRI scanner level accreditation such as from the ACR. Both of us have libraries of pictures of things stuck to MRI scanners, wheelchairs, gurneys, ventilators, pistols, you name it. Given the accidents that we’re able to track back to their source, it’s not as if these accidents are only happening at the handful of non-accredited providers. The fact that these accidents keep recurring at accredited providers, it begs the question, if these accidents are repeated, foreseeable and preventable, why don’t accreditation organizations have specific standards to interrupt them?

Why would a hospital that routinely does MRI studies on critically ill patients not have a medication pump or an anesthesia machine or a patient ventilator that is tested and labeled for use in MRI? Today, there are sites that will park a medication pump outside the MRI scanner room, leave the door open, and snake the IV tubing across the room to the patient because an MR Conditional infusion pump is prohibitively expensive.

What about the sites that either don’t have or choose not to use MR Conditional wheelchairs, insisting that they know what they can get away with and they know how far to keep that steel wheelchair away from the scanner? None of the accreditation organizations require that a hospital have MR Conditional equipment appropriate to the level of care that they deliver.

Another MRI risk that we haven’t really addressed in our podcast to date, MRI exams can sometimes burn patients. There are a few different mechanisms for this, but perhaps the most common way is when the patient’s arms are too close to the sidewalls of the tube. A uniform MRI protection identified in just about every MRI scanner manufacturer’s operator’s manual is to include padding between the patient and the tube. Despite being universal in the manuals, this simple and direct harm prevention isn’t part of any of the accreditation organization’s minimum standards.

So, I was curious about this, about how we have all of these Groundhog Day repeating MRI accidents, projectiles, patient burns, hearing damage, and how the accreditation minimums don’t seem to capitalize on the existing knowledge of how to prevent these types of accidents.

So, this is when you called the Joint Commission, right? Yeah.

About a year and a half ago, I wanted to know how or even if Redwood City MRI Accident prompted the Joint Commission to look at their standards. I had a phone conversation with a couple of Joint Commission executives. I won’t be naming them here. I wanted to know what kind of feedback loop was within their organization. In other words, how did information about preventable harm accidents work its way back through the organization to inform changes of their standards?

That makes sense. If there was a gaping hole in their standards and people were getting hurt as a result of it, surely they’d rush to plug that hole as soon as they’d identified it.

That was my thinking too. Joint Commission is notoriously opaque as an organization, and I couldn’t find anything about how they verify the effectiveness of their standards, so I thought I’d ask them outright.

And what did they have to say about that?

That’s the thing. They didn’t say much of anything specific. First, they tried to wave me off by saying they couldn’t talk specifically about their accreditation investigation into the Redwood City MRI accident. I tried to redirect the conversation by saying, I know you can’t talk about that specific investigation. And while my question was prompted by that incident, I was asking more broadly about how they used known injury accidents at their accredited providers to provide a real-world test of the effectiveness of their standards.

And did they? Do they now?

Well, I left that conversation from last year without a sense that they did. They did provide some ambiguous statements about actively maintaining the highest quality standards. But when I tested that assertion by asking, how, how exactly do you achieve that? They didn’t directly answer. But they said, relative to my interest in the Redwood City accident, that they believe that they had done some sort of formal stratification of MRI accidents that they investigated and that that fed into their review process. I asked for details of that stratification and how it factored into the review of their MRI standards. And it was around this point that they said they had to leave the call for other obligations.

So, there’s an assertion that these accidents are used to evaluate their standards, but no information on how they actually accomplished that.

Correct.

And another assertion that there’s some sort of classification for MRI accidents, specifically that feeds into their evaluation process for their standards.

Also correct.

But, no information on that call about either of those, right?

No. I did send about a half dozen emails to those same two executives, following up after that call, asking for the information. None of those emails got a response. I did send them another email asking if they’d comment for this episode on whether or how they review their MRI safety standards, either on a schedule or in response to specific events, like the Redwood City accident. After a few days, and a gentle reminder, we got a one-sentence response. Quote, we use all available data to review our requirements along with associated regulatory requirements. Period.

So not really a direct response to your questions. If we don’t know if this accident prompted Joint Commission to look at their own standards, what, if anything, did the Joint Commission find in their specific investigation of Redwood City Hospital?

We’ll probably never know. Unlike CMS or Cal/OSHA investigations, Joint Commission keeps all findings confidential. I sent a separate email asking, and I got an official response. Quote, each case is reviewed based upon whether the information provided gives evidence of serious ongoing violations of Joint Commission standards. The organization is reviewed for quality concerns consistent with Joint Commission standards, not whether substandard care was delivered in one individual case.

Not much substance there either. If their basis for identifying a problem is the existence of an ongoing violation, do we know if this could have been like the Cal/OSHA investigation in that if the scanner room door was closed when the Joint Commission sent someone to check, there was no ongoing violation, so therefore no problem.

We don’t know if they found any problem or violation of their standards. Even if there was a problem before, but not a violation when they show up on the day of, they may believe themselves to be incapable of investigating or citing. We just don’t know. But we have gotten similar statements from other authorities that if there’s not an ongoing problem when they show up, there’s not a regulatory problem.

So this entire episode was trying to answer the question of whether the hospital’s accreditation was an effective stand-in for what was lacking in terms of state license. While the Joint Commission did have some point-of-care MRI safety standards, which is more than we can say for the state of California’s Department of Public Health, those standards don’t appear to have been particularly on point for interrupting the cause of our accident. And unlike the government quality and safety monitors of CMS and Cal/OSHA, any investigative findings from the TJC are likely to be concealed from the public forever. Lastly, we don’t currently have any indication that TJC’s standards evolve in response to this specific event.

So I guess that makes our answer to the question of whether formally or informally, we believe that the Joint Commission could be a meaningful stand-in for a state license authority that doesn’t regulate MRI. We think that’s pretty emphatic no. While the Joint Commission does better insofar as they clearly have MRI safety in their remit, while CDPH insists that they don’t have MRI safety in theirs, the Joint Commission’s MRI-specific standards and survey regime weren’t effective at preventing this accident. Because of its opacity, we have no idea whether there was a meaningful investigation and Joint Commission hasn’t, so far at least, indicated that it learned from this MRI accident with the aim of strengthening their standards to be more effective in the future. And what about the accreditation? Sir?

Redwood City Hospital held accreditation from… Joint Commission, sir. Right. And they assert that one of the goals of their accreditation is zero harm. Well, yes.

And the hospital was surveyed by Joint Commission? A few times, at least, sir.

And did any of those surveys identify MRI safety deficiencies?

Not that I’m aware of, sir.

And when the CMS report came out, it had 13 pages of deficiencies listed?

It did.

And enterprise accreditation is supposed to be a demonstration that the hospital met the CMS requirements, right? I think I see where you’re going with this. If our accreditation is supposed to be a demonstration of CMS compliance with an aim of zero harm and our MRI service apparently cleared multiple surveys, how did we wind up with 13 pages of deficiencies after an accident that nearly killed a nurse?

In our next episode, we’re going to draw our third series to a close with a big picture recap. So 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 multiple interactions with representatives from the Joint Commission, the CMS standards and interpretations for radiology, the reports from both CMS and Cal/OSHA, as well as some confidential sources. Our introductory dramatization of what we think Kaiser bigwigs must have thought about their accreditations’ promise of safety, that dramatization was voiced by Brandon Grugle and Misha Stanton.

If you have any information about this incident or any MRI accidents, please reach out to us through our website, invisibleforcepodcast.com. Episodes, show notes, and a tip line are always available there. You can also leave us a voicemail with information about this accident or any at 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, health care policy, or MRI, and something in this story just doesn’t make sense to you, we’d like to hear from you. Lastly, we’d like to ask you to like and share our podcast with your friends and your colleagues. With your help, we’ll unravel the mystery of what happened and with a little bit of luck, we’re going to help make sure that accidents like this don’t ever occur again.