An MRI machine traps a nurse in a freak accident

Safety concerns have been raised about a California medical center after a nurse was recently pinned between an MRI machine and a bed during a freak accident, a KTVU investigation has revealed.

Nurse Aina Cervantes suffered “crushing injuries” that required surgery after the magnetic force of an MRI machine suddenly pulled a hospital bed toward her.

Cervantes was caring for a patient in bed at the time of the accident at a Redwood City medical center operated by California-based Kaiser Permanente.

The patient fell out of bed and was not injured, but Cervantes became trapped between the front of the pipe instrument and the bed.

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A nurse was injured in an MRI accident. (Shoulders)

“I was pushed out of bed,” Cervantes told investigators in a report conducted by the California Department of Occupational Safety and Health (Cal/OSHA). “Basically, I was running backwards. If I didn’t run, the bed would crush me underneath me.”

Documents obtained by the station showed that Cervantes suffered a severe laceration that required surgery that included the removal of two embedded screws.

Although the incident occurred in February, the investigation was not completed until several months later.

The California Department of Public Health’s investigation concluded that the Redwood City Center “failed to provide radiation services in a safe manner.” It revealed several errors that led to the accident involving the device, which uses magnetic fields and radio waves to create images of the body to identify or diagnose medical conditions.

Investigators say there were no MRI personnel inside the room during the incident. No one, including the patient, was examined, and the door to the room was left open. The safety alarm system never sounded.

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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.

The MRI machine is broken

A nurse was pinned between an MRI machine and a bed during a freak accident, a KTVU Fox 2 investigation has revealed. (Shoulders)

The California Department of Public Health’s investigation stated that “numerous safety failures… created a culture of unsafe practices.”

Sheila Gilson, senior vice president of Kaiser Permanente San Mateo, said teams responded quickly and participants “immediately received the care and support they needed.”

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“This was a rare event, but we are not satisfied until we understand why the incident occurred and implement changes to prevent it from happening again,” Gilson said.

KTVU sources claim this was not the only incident at Redwood City Hospital. The photo provided to the station shows a medical equipment cart attached to an MRI scanner. Kaiser Permanente said the image is likely from an incident in March 2015, when no patients or staff were injured.

“As an organization committed to continuous learning improvement, Kaiser Permanente fully investigated the incident and used what we learned to make specific process changes to enhance safety,” Gilson’s statement said.

The MRI machine is broken

MRI accident in the Gulf region. (Shoulders)

Kaiser Permanente faces an $18,000 fine from Cal/OSHA for alleged errors and a workplace injury incident.

Tobias Gilke, an expert in magnetic resonance imaging, said that machines do not stop magnetic attraction once they are attached to an object.

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“It keeps pulling and pulling and squeezing to try to bring the magnetically attracted object closer to the MRI scanner itself,” Gilke said.

Gilk’s research into MRI machine accidents includes federal data showing that as the number of scans and examinations increases, so do accidents.

It is estimated that thousands of accidents go unreported every year.


“Personally, I find it very frustrating,” Jelke said. “We know that MRI accidents can occur when best practices are not followed.”

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