MRI machine pulled bed, crushed nurse
The nurse's injuries required emergency surgery to remove 2 of the machine's screws from her body

By Michael Dorgan
Published October 28, 2023 6:58pm EDT

Safety concerns are being raised about a medical center in California after a nurse was recently pinned between an MRI machine and a bed during a freak accident, an investigation by KTVU uncovered.

The nurse, Ainah Cervantes, suffered "crushing injuries" that required surgery after the MRI machine’s magnetic force suddenly pulled a hospital bed toward it.

Cervantes was tending to a patient on a bed at the time of the mishap at a medical center in Redwood City operated California-based Kaiser Permanente.

The patient fell from the bed and was uninjured, but Cervantes became sandwiched between the front of the tube-shaped machine and the bed.



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

Cervantes endured a severe laceration that required surgery that included the removal of two embedded screws, documents obtained by the station show.

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

The probe by the California Department of Public Health found the Redwood City center "failed to provide radiologic services in a safe manner." It revealed several missteps 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 medical conditions.

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

The incident also breached 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 many safety failures … created a culture of unsafe practices," the California Department of Public Health’s investigation stated.

Sheila Gilson, senior vice president for Kaiser Permanente San Mateo, said 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 said.

KTVU sources allege this wasn’t the only incident at the Redwood City hospital. A photo provided to the station shows a medical equipment cart stuck to an MRI scanner. Kaiser Permanente said the photo was likely from an incident in March 2015, when no patients or employees were hurt.

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

Kaiser Permanente is facing an $18,000 fine from Cal/OSHA for the alleged missteps and a workplace injury accident.

Tobias Gilk, an MRI expert, said the machines do not stop being magnetically attracted once they attach to an object.

"It keeps pulling and pulling and pulling, squeezing to try to get the magnetically attracted object closer to, in contact with the MRI scanner itself," Gilk said.

Gilk’s research into MRI machine incidents includes federal data that shows as the number of scans and exams increase, so do accidents.

He estimated thousands of incidents go unreported every year.

"Personally, I find it very frustrating," said Gilk. "We know MRI accidents can happen when best practices aren’t followed."

quote:

Kaiser Permanente is facing an $18,000 fine from Cal/OSHA

That's nothing to KP.

And these are the same nurses who just striked for more money. Maybe they should strike for more training.

I need one of those to help find a fish hook I dropped in the carpet.

I was just in one a week ago. I call it a got damn coffin. Hate that machine. 5 minutes of that, because the wonderful nurse or whatever she is called, had me do everything twice, was 5 of the hardest minutes of my entire life.

Ages ago,clear back in the 1900's.

Some supermarkets experimented with mounting tall pieces of conduit on shopping carts to prevent them from being taken from the building.

Perhaps that would work for the rolling metal beds and
Diagnostic rooms ?

The last time I heard an MRI accident this stupid, a patient had a ND and shot himself, b/c he failed to remove his CCW before getting an MRI.

After looking up, turns out it happens more often than I thought.

Long Island patient charged with reckless endangerment after gun discharges in MRI exam room

Gun discharges in MRI at Indianapolis Veterans Affairs hospital

Lawyer dies after gun triggered by hospital MRI scanner

Spontaneous Discharge of a Firearm in an MR Imaging Environment

quote:

Originally posted by XLT:
I need one of those to help find a fish hook I dropped in the carpet.

...and 1911 recoil springs.

quote:

Originally posted by Prefontaine:
I was just in one a week ago. I call it a got damn coffin. Hate that machine. 5 minutes of that, because the wonderful nurse or whatever she is called, had me do everything twice, was 5 of the hardest minutes of my entire life.

Five minutes? With all done twice? I’ve had half a dozen MRI sessions, each lasting 30 minutes to an hour. (The hour session was because a repeat was needed.)

Lots of weird, but interesting noises. Amazing, and wonderful, technology.

quote:

Originally posted by XLT:
I need one of those to help find a fish hook I dropped in the carpet.

Don’t worry, you’ll find it…

quote:

Originally posted by Jim Shugart:

quote:

Originally posted by XLT:
I need one of those to help find a fish hook I dropped in the carpet.

...and 1911 recoil springs.

I was thinking AR-15 detent springs. Not sure if the detents themselves are magnetic or not...

quote:

Originally posted by Prefontaine:
I was just in one a week ago. I call it a got damn coffin. Hate that machine. 5 minutes of that, because the wonderful nurse or whatever she is called, had me do everything twice, was 5 of the hardest minutes of my entire life.

Try spending 45 minutes having a breast MRI, lying on your stomach with your sternum resting on a metal bar and your boobs hanging down through holes in the table. Thankfully I haven’t had to have a biopsy during one, or at least not yet.

An MRI tech told me that they did not go through a woman's hair carefully. She had to have minor surgery to have a bobby pin extracted from her nose.

quote:

Five minutes? With all done twice? I’ve had half a dozen MRI sessions, each lasting 30 minutes to an hour. (The hour session was because a repeat was needed.)

^^^^^^^^^^^^^^^^^^^^^
He has discount insurance. If you are claustrophic they will give you benzos. If it is really bad IV sedation is also a possibility.

Why do I know more about this than the nurse that pushed that bed into the room?
They told me, "Metal or piercings, bad". That's all I needed to imagine. A whole bed?

By using the term "nurse" in the article, they give the impression the woman is a Registered Nurse. Was she an RN?

If someone completed nursing school and brought that bed near the door, they ignored not only all of the signage but also her training. (You would think.) If she was an RN, it is concerning...

The MRI scans I have had all had multiple doors with clear warnings before you got into the room.

quote:

Originally posted by MelissaDallas:

quote:

Originally posted by Prefontaine:
I was just in one a week ago. I call it a got damn coffin. Hate that machine. 5 minutes of that, because the wonderful nurse or whatever she is called, had me do everything twice, was 5 of the hardest minutes of my entire life.

Try spending 45 minutes having a breast MRI, lying on your stomach with your sternum resting on a metal bar and your boobs hanging down through holes in the table. Thankfully I haven’t had to have a biopsy during one, or at least not yet.

Sounds painful. I was in it one hour 45 minutes. Because she had to do everything twice. 2nd run I was on my stomach, in the Christopher Reeves Superman position. Tendon below elbow that feeds your top forearm and all your fingers is badly torn. It was excruciating holding that position for that long. Not my first MRI by any means. Due to the injury this trip was a mafk.

Those who cannot tolerate the "classic" MRI can ask for the open one.

quote:

Originally posted by steve495:
By using the term "nurse" in the article, they give the impression the woman is a Registered Nurse. Was she an RN?

If someone completed nursing school and brought that bed near the door, they ignored not only all of the signage but also her training. (You would think.) If she was an RN, it is concerning...

The MRI scans I have had all had multiple doors with clear warnings before you got into the room.

My take is that the door to the MRI suite was left open and should not have been and should have set off an alarm because of that but did not. The nurse was pushing the bed down the hall outside the suite and as the bed passed the open door it sucked the bed, nurse and patient into the suite. Not that an idiot intentionally pushed a metal bed into the MRI suite.

^^^You describe a scene not dissimilar to that of a 'Black Hole'! One has to wonder if the Nurse was pushing the bed down the hall, how is it that she ended up between the bed and the MRI?