Safety concerns have been raised about a California medical center after a nurse was recently trapped between an MRI machine and a bed in 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 towards her.
Cervantes was caring for a patient on a bed at the time of the accident at a Redwood City medical center run by California-based Kaiser Permanente.
The patient fell out of bed and was not injured, but Cervantes became trapped between the front of the tube-shaped 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). “I was basically 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, according to documents obtained by the station.
Although the incident occurred in February, the investigation was not completed until several months later.
The investigation by the California Department of Public Health found that the Redwood City center “failed to provide radiology services in a safe manner.”
It revealed several missteps leading to the incident involving the machine, which uses magnetic fields and radio waves to create images of the body to identify or diagnose medical problems.
Investigators say no MRI personnel were present inside the room during the incident.
No one, including the patient, was ever screened and the room door was left open. The security alarm system never sounded.
The incident also violated several Kaiser MRI security 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 numerous safety failures…created a culture of unsafe practices,” the California Department of Public Health investigation said.
Sheila Gilson, senior vice president of Kaiser Permanente San Mateo, said crews responded quickly and those involved “immediately received the care and support they needed.”
“It was a rare event, but we’re not satisfied until we understand why an accident happens and implement changes to prevent it from happening again,” Gilson said.
KTVU sources say this wasn’t the only incident at Redwood City Hospital.
A photo provided to the station shows a cart of medical equipment stuck to an MRI scanner. Kaiser Permanente said the photo was likely from an incident in March 2015, in which 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 the alleged missteps and a workplace accident.
Tobias Gilk, an MRI expert, said the machines continue to be magnetically attracted once attached to an object.
“It keeps pulling and pulling and pulling, squeezing to try to get the magnetically attracted object closer, in contact with the MRI scanner itself,” Gilk said.
Gilk’s research on MRI machine incidents includes federal data that shows accidents increase as the number of scans and exams increases.
He estimates 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.”