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 has revealed.
The nurse, Ainah Cervantes, suffered a “crushing injury” that required surgery after the magnetic force of the MRI machine suddenly pulled the hospital bed towards her.
Cervantes was treating a bedridden patient at the time of the accident at a medical center in Redwood City operated by California-based Kaiser Permanente.
The patient fell from the bed and was uninjured, but Cervantes was pinned between the front of the tubular machine and the bed.
“I was pushed by the bed,” Cervantes told investigators in a report conducted by the California Division of Occupational Safety and Health (Cal/OSHA). “Basically, I ran backwards. If I don’t run, the bed will crush me under.”
Cervantes suffered severe injuries that required surgery including the removal of two embedded screws, documents obtained by the station show.
The nurse was helping a patient in bed when an MRI machine crushed him at a medical center in Redwood City run by California-based Kaiser Permanente. KTVU
Although the incident occurred in February, the investigation was not completed until several months later.
An investigation by the California Department of Public Health found the Redwood City center “failed to provide radiology services in a safe manner.”
It revealed several mistakes 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 pinned between the MRI machine and the bed, an investigation by KTVU Fox 2 reported. KTVU
Investigators said no MRI personnel were present in the room at the time of the incident.
No one, including the patient, was ever screened, and the door to the room was left open. The security alarm system never went off.
The incident also violated several Kaiser 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 door alarms annually as recommended.
“Many safety failures … created a culture of unsafe practices,” the California Department of Public Health investigation stated.
Sheila Gilson, senior vice president for Kaiser Permanente San Mateo, said the team responded quickly and those involved “immediately received the care and support they needed.”
“These are rare occurrences, but we’re not satisfied until we understand why accidents happen and implement changes to prevent them from happening again,” Gilson said.
KTVU sources claim this is not the only incident at the Redwood City hospital.
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A photo provided to the station shows a car of medical equipment stuck in an MRI scanner. Kaiser Permanente said the photo is likely from an incident in March 2015, when no patients or employees were injured.
“As an organization committed to continuous learning improvement, Kaiser Permanente fully investigated the incident and used what we learned to make specific operational changes to improve safety,” Gilson’s statement said.
Kaiser Permanente faces $18,000 in fines from Cal/OSHA for alleged missteps and workplace injury accidents.
Tobias Gilk, an MRI expert, said the machine does not stop being magnetically attracted when it is attached to an object.
“It keeps pulling and pulling and pulling, squeezing to try to bring the magnetically attracted object closer, into contact with the MRI scanner itself,” Gilk said.
Gilk’s research into MRI machine incidents includes federal data showing that as the number of scans and exams increases, so do accidents.
He estimates thousands of incidents go unreported each year.
“Personally, I think it’s very disappointing,” Gilk said. “We know MRI accidents can happen when best practices aren’t followed.”
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Source: thtrangdai.edu.vn/en/
