Safety concerns are emerging at a medical center in California after a nurse was recently trapped between an MRI machine and a bed during a freak accident, a KTVU investigation found.
The nurse, Ainah Cervantes, suffered “crush injuries” that required surgery after the magnetic force of the MRI machine suddenly pulled a hospital bed toward her.
Cervantes was caring for a patient in a bed at the time of the mishap at a medical center in Redwood City operated by California-based Kaiser Permanente.
The patient fell out of bed and was uninjured, but Cervantes was trapped between the front of the tube-shaped machine and the bed.
“The bed was pushing me,” Cervantes told investigators in a report by the California Division of Occupational Safety and Health (Cal/OSHA). “Basically, I was running backwards. If I didn’t run, the bed would crush me underneath.”
Cervantes suffered a severe laceration that required surgery that included the removal of two embedded screws, documents obtained by the station show.
The nurse was helping a patient in a bed at the time she was crushed by the MRI machine at a medical center in Redwood City operated by California-based Kaiser Permanente. KTVU
Although the incident occurred in February, the investigation was not completed until several months later.
The California Department of Public Health investigation found that the Redwood City facility “failed to safely provide radiological services.”
It revealed several errors that led 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.
The nurse was trapped between the MRI machine and a bed, a KTVU Fox 2 investigation reported. KTVU
Investigators say there were no MRI personnel present inside the room during the incident.
No one, not even the patient, was examined and the door to the room was left open. The security alarm system never sounded.
The incident also violated several of Kaiser’s MRI safety policies, according to the report.
Incident investigation records show that 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 investigation stated.
Sheila Gilson, senior vice president at Kaiser Permanente San Mateo, said teams responded quickly and those involved “immediately received the care and support they needed.”
“This was a rare occurrence, but we are not satisfied until we understand why an accident occurs and implement changes to prevent it from happening again,” Gilson said.
KTVU sources allege this was not the only incident at the Redwood City hospital.
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A photo provided to the station shows a cart of medical equipment attached to an MRI scanner. Kaiser Permanente said the photo was likely from an incident in March 2015, when no patients or employees were injured.
“As an organization committed to continuous learning improvement, Kaiser Permanente thoroughly investigated the incident and used what we learned to make specific operational changes to improve safety,” Gilson’s statement said.
Kaiser Permanente faces an $18,000 fine from Cal/OSHA for alleged errors and a workplace accident.
Tobias Gilk, an MRI expert, said the machines do not stop being magnetically attracted once they attach themselves to an object.
“It keeps pulling and pulling and pulling, squeezing to try to get the magnetically attracted object closer and into contact with the MRI scanner itself,” Gilk said.
Gilk’s research into incidents with MRI machines includes federal data showing that as the number of scans and exams increases, so do accidents.
He estimated that thousands of incidents go unreported each year.
“Personally, I find it very frustrating,” Gilk said. “We know that MRI accidents can happen when best practices are not followed.”
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Source: vtt.edu.vn