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Kaiser Permanente fined $18,000 for MR incident that injured nurse

by John R. Fischer, Senior Reporter | October 31, 2023
MRI
Kaiser Permanente Redwood City Medical Center
Kaiser Permanente Redwood City Medical Center has been hit with an $18,000 fine for a safety violation that led to a nurse being pinned between an MR scanner and a metal bed.

The incident occurred on February 23, 2023. The nurse, whose pelvis, right leg, and abdomen were injured, was pushing an ICU bed toward the door to the MR room, which had been left open when she was sucked in. She spent several days in the hospital recovering, according to the Palo Alto Daily Post.

The California Occupational Safety and Health Administration fined the hospital for failing to have a plan to ensure the door remained closed. Kaiser told Cal/OSHA that hospital executives met hours after the accident to evaluate possible corrective actions, posted warning signs between the prep and MR rooms, and shared a safety alert with all department managers to prevent another incident.
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In a statement, Kaiser told HCB News that the incident was a “rare occurrence,” and has been investigated by it, HHS, CMS, and Cal/OSHA, resulting in "short- and long-term actions" that strengthen its policies and staff education on MR safety and ensure compliance with American College of Radiology safety guidelines to prevent future incidents.

But MR safety expert Tobias Gilk, senior vice president of the radiology equipment planning and facility design firm RAD-Planning, says attributing an open door is “a vast oversimplification,” and criticized the MR suite’s “poor” design, moving patients there on ICU beds, and the ferromagnetic detector being turned off with no indication of who disabled it.

“The OSHA report contained a copy of the MR safety checklist that ACR uses for their MR accreditation program. That safety checklist gave the site perfect marks for MR safety when, clearly, there were structural problems, training problems, oversight problems and, per the reports, routine violations of safety policy,” he told HCB News.

Additionally, the nurse’s MR safety training listed by the hospital contrasts with the OSHA report, which indicates that she was only in the MR suite once before.

Gilk also says the director of radiology's statement in the California Department of Health report that certain radiologists were responsible for clinical MR safety is a "red flag" and that his appointment as MR medical director indicates a “huge breakdown in responsibility and chain of command.”

"Most radiologists I know have workloads that don’t permit time inside the MR suite to make sure that site policies are consistently implemented at the point of care. I wonder if the radiologist’s designation as MRSO was just to ‘check a box,’” he said.

Kaiser says CMS has approved its corrective plans, which are validated with regular monitoring, auditing, and reporting to physician and hospital leaders.

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