BY EMILY MIBACH
Daily Post Staff Writer
Kaiser Permanente in Redwood City is paying an $18,000 fine after an MRI machine unexpectedly pulled a metal bed and a nurse several feet, leaving her with serious injuries.
She suffered injuries to her pelvis, right leg and abdomen, according to documents the Post obtained from the California Occupational Safety and Health Administration. She spent several days in the hospital recovering.
The MRI machine, which contains powerful magnets that create a strong magnetic field, produces three-dimensional images, giving doctors an inside view of a patient’s body. The machine is shaped like a donaught and it takes up a good part of the room.
Patients are placed on a bed that is slid into the MRI.
The MRI is powerful enough to fling a wheelchair across a room, the National Institute of Biomedical Imaging and Bioengineering said in an online bulletin.
The nurse was in the preparation area with a patient and another nurse on Feb. 23. Typically, the door between the prep area and the room with the MRI is closed, according to the Cal/OSHA documents.
Once the patient was prepped, the nurse began to move the bed toward the door to the MRI room. However, the door was open, and as the nurse got closer to the door with the metal bed, she and the bed were suddenly flung toward the machine, pinning her between the machine and bed, according to various witness reports to Cal/OSHA.
Cal/OSHA fined Kaiser $18,000 for not having a plan to make sure the door between the prep area and MRI room stayed closed.
The Post reached out to Kaiser about the incident but did not get a response by deadline.
Kaiser, in documents submitted to Cal/OSHA, laid out its response, saying that within a few hours of the accident, hospital leaders met to find ways to make sure this sort of thing did not happen again. Some leaders began a deep dive into what corrective actions needed to happen, posted warning signs between the prep room and MRI room and shared a safety alert with all department managers at the hospital.
The chief executive nurse at the hospital also met with the nurse’s husband and mother to “offer support and assistance,” according to the paperwork Kaiser filed with Cal/OSHA.
A day after deadline, Kaiser Vice President and Area Manager Sheila Gilson sent the Post a response which read in part: “Our 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 occurring again.”
Gilson’s statement continued, saying Kaiser cooperated with investigators from U.S. Department of Health & Human Services, Centers for Medicare and Medicaid Services (CMS) and Cal/OSHA. “This has resulted in short- and long-term actions that strengthen our policies, practices, and staff education for MRI safety; ensure continued alignment with the American College of Radiology Safety Guidelines; and serve to prevent any such occurrence in the future. Our plans have been approved by CMS and are being validated by regular monitoring and auditing, and reporting to physician and hospital leadership,” Gilson said in her statement.
No reason for the state to issue a fine. Employer is required by law to pay workers’ compensation benefits anyway, regardless of fault. Kaiser doesn’t need the threat of fines to remedy these unfortunate events. They don’t want injured employees.
If you’re involved in a car accident, you may end up paying higher insurance premiums, but the state doesn’t pile on with fines…unless the driver violated the civil or criminal code separate and distinct from the accident itself – like speeding, driving with blood alcohol limit above 0.8, suspended license, without seat belt. Where is the law that says it is against the law: for not having a plan to make sure the door between the prep area and MRI room stayed closed?
Unlike your car accident analogy, where the drivers are essentially ‘peers’ in terms of their level of understood responsibility and minimum capabilities, the relationship between a hospital and either individual employees or individual patients is nowhere close to a peer structure. The hospital has resources vastly greater than employees or peers to help assure known risks are appropriately managed. And a hospital, particularly one that celebrates their own safety accolades, has an even greater duty to the safety of persons in their care.
If, hypothetically, it turned out that this hospital hadn’t clearly established who had direct responsibility for MRI safety, or violated its own written policies with regard to MRI safety training of the people involved in the accident, or didn’t follow the hospital design minimums of their MRI suite, or perhaps even failed to report this accident themselves, would any of those items change your thinking on the appropriateness of a fine?
I’m going to disagree with you on the resource and risk disparity between hospital and employee. In many, if not most, cases, workers have as much knowledge and ability as the employer to prevent the accident in question. The risk in the MRI room is well known.
You are forgetting about the incentive upon the employer. If the accident level in the hospital became too high, then further wage increases would be needed to attract and hold the best workers. The hospital also has an incentive to take care of its employees as a necessary by-product of the discharge of their obligation to care for patients.
As for your hypotheticals, none of them would change my mind. If you had said hospital operated MRI frequency range beyond regulatory safety values, then maybe I would want to hear more arguments from both sides…but probably still wouldn’t affect my opinion. I would need something intentional or willful by the employer.
I agree with Alvin. Plus, there were two nurses in the room. Shouldn’t the one be aware of what the other is doing before he/she turns on the machine?
The magnetic field for the MRI is always on. There is no ‘turning it on’ with respect to the magnetic field.
Per both the OSHA report (that’s mentioned in the article) and the CMS / CDPH report (not mentioned in the article), the hospital purportedly trained the nurse and nurse-aide in MRI safety, but the scope of this accident calls into question whether the hospital’s training was anywhere close to appropriate.
The unsafe condition that led to the accident was entirely foreseeable, that’s the problem. They had a prep area close enough to the MRI that large metal objects could be attracted in. The door does not stop the magnetic field, it keeps the (normal steel) bed from going into the magnet. This design is unsafe. There are regulations that require signage and policies to prevent this; there are areas (called Zone 1) that unscreened people and normal metal objects are excluded. They had a Zone 1 area and it was not properly labeled and controlled.
This happened in Feb. And now it’s Oct. when we learn about it. Why did Kaiser keep this secret from the public and their own staff? (Thank God the Daily Post exists to dig out things like this!!!)
Gina, This was not kept a secret and it has been discussed at length both inside of Kaiser and in MRI Safety circles since the incident occurred (this has been all over LinkedIn and other social platforms for MRI safety). Hopefully we will never stop discussing this event. The amount of this fine is insulting as the facility probably recouped this “expense” in less than a day’s work in 1 MRI scanner.