Freak accident in Mountain View exposes MRI safety flaws
MOUNTAIN VIEW, Calif. - A patient recently escaped a harrowing experience while waiting for an MRI in a Mountain View imaging room.
A trainee brought a wheelchair – one that wasn't made to be near an MRI machine – into the room. And because of the magnetic force of the machine, the wheelchair was sucked across the room, attaching itself sideways to the MRI scanner door, narrowly missing the patient.
This freak occurrence is raising concerns among safety advocates, including MRI safety expert, Tobias Gilk, who shared this example and images with KTVU. He said a witness sent him photos from Mountain View Center Imaging, operated by Sutter Health, on April 1.
"There was a patient on the table and this trainee brought the non-MRI-safe-wheelchair into the room, then the magnet attracted it and went flying at the scanner," he said.
Photo provided by Tobias Gilk, depicting MRI incident on April 1, 2024.
It's the latest in a string of potentially dangerous scenarios with MRI scanners in the state.
Gilk said there are standard practices and training information for people who work in the MRI environment.
"My frustration comes out of the fact that these are almost 100% preventable through existing best practices," said Gilk.
Dr. Stephanie Tan, a radiologist in Canada and international MRI expert, said she believes safety protocols were not followed.
"It's not standardized anywhere, not in the states, not in Canada, not in Europe. The reporting is not standardized," she said.
KTVU struggled to get clarity from multiple regulatory authorities about reporting standards.
In an email, the California Department of Public Health said that its radiological health branch was informed, through a public inquiry, of an incident involving magnetic resonance imaging at a health care facility in Mountain View.
The Department of Health added that because the MRI is outside their jurisdiction, all questions should be asked of the California Medical Board.
But that didn't yield any answers, either.
The California Medical Board told KTVU to ask the Department of Health, because it does not "oversee these types of medical offices."
The Mountain View site is accredited through the American College of Radiology.
For its part, Sutter Health said that "ensuring the safety and excellence of our patient care is always our top priority. Unfortunately, accidents can still occur. Thankfully, no one was seriously injured, and corrective action was promptly taken."
Sutter Health added that its organization adheres to "strict standards and reports to the appropriate oversight and accreditation bodies as required."
Additionally, Sutter Health said its organization conducts "thorough reviews to identify opportunities for learning and improvement."
But what actually happened has not been publicly revealed.
When KTVU requested a report to see the details, the American College of Radiology said they don’t comment on specific local site matters.
An ACR spokesperson said people can report incidents and accredited sites are subject to unannounced visits, but they do not "regulate" medical sites, and sites are not required to report issues, failures, or injuries.
This safety incident follows a string of others just like it.
Last fall, KTVU investigated an incident where medical equipment was sucked into an MRI machine at Kaiser Permanente Redwood City, injuring a nurse, and another at the same site in March 2015, when a medical equipment cart got sucked into the scanner.
Picture of MRI accident that crushed Kaiser nurse Ainah Cervantes in Redwood City back in Februrary
Photos collected by Gilk show multiple incidents reported to the California Health Department, including another wheelchair-into-MRI accident in January just outside of Los Angeles in Whitter, Calif., and another at SimonMed Imaging in Beverly Hills.
In August 2016, an 82-year-old man died after an MRI incident at Kaiser Permanente Zion Medical Center in San Diego.
While fatal incidents are rare, radiologists said the number of failures is on the rise.
"It's kind of expected that it's a problem because there's an increasing number of MRIs being performed every year, which is up to 30 million in the states," Tan said.
Gilk said there should be an agency which standardizes reporting and enforces consequences.
"I think that there's an obligation on the part of the state, in one form or another, to make sure that, you know, the citizens of the state of California, when they go seeking health care, that they are assured some minimum levels of quality and safety," he said.
Consequences and corrective action in this case were not disclosed, but in other cases, the state has issued fines to medical sites which failed to provide a safe environment for staff and patients.
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