Safety concerns are being raised about a medical center in California after a nurse was recently pinned between an MRI machine and a bed during a freak accident, an investigation by KTVU uncovered.
The nurse, Ainah Cervantes, suffered "crushing injuries" that required surgery after the MRI machine’s magnetic force suddenly pulled a hospital bed toward it.
Cervantes was tending to a patient on a bed at the time of the mishap at a medical center in Redwood City operated California-based Kaiser Permanente.
The patient fell from the bed and was uninjured, but Cervantes became sandwiched between the front of the tube-shaped machine and the bed.
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"I was getting pushed by the bed," Cervantes told investigators in a report conducted by the California Division of Occupational Safety and Health (Cal/OSHA). "Basically, I was running backwards. If I didn’t run, the bed would smash me underneath."
Cervantes endured a severe laceration that required surgery that included the removal of two embedded screws, documents obtained by the station show.
Though the incident occurred in February, an investigation was not completed until several months later.
The probe by the California Department of Public Health found the Redwood City center "failed to provide radiologic services in a safe manner." It revealed several missteps leading up to the incident involving the machine, which uses magnetic fields and radio waves to create images of the body to identify or diagnose medical conditions.
Investigators say there were no MRI personnel present inside the room during the incident. No one, including the patient, was ever screened, and the door to the room was left open. The safety alarm system never sounded.
The incident also breached several of Kaiser’s MRI safety policies, according to the report. Incident investigation records show some employees never received required safety training, and the hospital also failed to test the door alarm annually as recommended.
"The many safety failures … created a culture of unsafe practices," the California Department of Public Health’s investigation stated.
Sheila Gilson, senior vice president for Kaiser Permanente San Mateo, said teams responded quickly and those involved "immediately received the care and support they needed."
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"This was a rare occurrence, but we are not satisfied until we understand why an accident occurs and implement changes to prevent it from occurring again," Gilson said.
KTVU sources allege this wasn’t the only incident at the Redwood City hospital. A photo provided to the station shows a medical equipment cart stuck to an MRI scanner. Kaiser Permanente said the photo was likely from an incident in March 2015, when no patients or employees were hurt.
"As an organization committed to continuous learning improvement, Kaiser Permanente fully investigated the incident and used what we learned to make specific operation changes to enhance safety," Gilson’s statement says.
Kaiser Permanente is facing an $18,000 fine from Cal/OSHA for the alleged missteps and a workplace injury accident.
Tobias Gilk, an MRI expert, said the machines do not stop being magnetically attracted once they attach to an object.
"It keeps pulling and pulling and pulling, squeezing to try to get the magnetically attracted object closer to, in contact with the MRI scanner itself," Gilk said.
Gilk’s research into MRI machine incidents includes federal data that shows as the number of scans and exams increase, so do accidents.
He estimated thousands of incidents go unreported every year.
"Personally, I find it very frustrating," said Gilk. "We know MRI accidents can happen when best practices aren’t followed."
