Safety concerns are being raised about a medical center in California after a recent freak accident left a nurse trapped between an MRI machine and a bed, a KTVU investigation has found.
Nurse Ainah Cervantes suffered “crush injuries” that required surgery after the magnetic force of the MRI machine suddenly pulled a hospital bed toward her.
At the time of the accident, Cervantes was caring for a patient lying on a bed at a medical center in Redwood City operated by Kaiser Permanente of California.
The patient fell from the bed and was unharmed, but Cervantes became trapped between the front of the tubular machine and the bed.
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A nurse was injured in an MRI accident. (KTVU)
“I was jostled on the bed,” Cervantes told investigators in a report from the California Department of Occupational Safety and Health (Cal/OSHA). “Basically I was running backwards. If I didn’t run, the bed underneath would crush me.”
Cervantes suffered a severe laceration that required surgery to remove 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 California Department of Public Health’s investigation found that Redwood Town Center “failed to provide radiology services in a safe manner.” Several missteps were revealed 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 diseases.
According to investigators, there were no MRI personnel in the room during the incident. No one, including the patient, was ever examined and the door to the room remained 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 some employees never received required safety training and the hospital also failed to test the door alarm annually as recommended.
A KTVU Fox 2 investigation found that a nurse became trapped between an MRI machine and a bed in a freak accident. (KTVU)
“The many safety deficiencies … have 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 teams responded quickly and those involved “immediately received the care and support they needed.”
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“It was rare, but we are not satisfied until we understand why an accident occurs and take steps to prevent it from happening again,” Gilson said.
KTVU sources claim this wasn’t the only incident at the Redwood City hospital. A photo provided to the station shows a medical equipment cart attached to an MRI scanner. Kaiser Permanente said the photo likely came from an incident in March 2015 in which no patients or employees were injured.
“As an organization committed to continuous learning improvement, Kaiser Permanente comprehensively investigated the incident and used our findings to make specific operational changes to enhance safety,” Gilson’s statement said.
MRI accident in the Bay Area. (KTVU)
Kaiser Permanente faces an $18,000 fine from Cal/OSHA for alleged misconduct and a workplace accident.
Tobias Gilk, an MRI expert, said the machines do not stop being magnetically attracted once they are attached to an object.
“It pulls and pulls and pulls and pushes to try to bring the magnetically attracted object closer to and into contact with the MRI scanner itself,” Gilk said.
Gilk’s research on MRI machine incidents includes federal data showing that as the number of scans and exams increases, so do the number of accidents.
He estimates that thousands of incidents go unreported each year.
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“I personally find it very frustrating,” Gilk said. “We know that MRI accidents can happen when best practices are not followed.”
Michael Dorgan is a writer for Fox News Digital and Fox Business.
You can send tips to [email protected] and follow him on Twitter @M_Dorgan.