The Most Infamous MRI Accident: Colombini At Westchester

The single accident that really galvanized the very existence of the MRI safety movement was an accident that occurred in 2001 at Westchester Medical Center in New York State. In that tragedy, a steel oxygen cylinder was brought into the MRI room while Michael Colombini, a six-year old boy, was receiving a post-operative MRI to confirm they doctors had successfully removed his brain tumor.

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In order for that accident to occur, a few standard procedures had to go awry, and not in ways that you might think. The anesthesiologist’s primary goal was to get his patient oxygen. The Technologists’ primary goal was to figure out why the oxygen (which the anesthesiologist was yelling for) wasn’t working. The nurse passing the MRI unit’s primary goal was to help out when she heard someone calling for help. This accident, like so many others, was the product of well-intended efforts in an environment where the rules are all imperceptibly changed.

There were a number of interventions that could have potentially broken the chain of events that resulted in this fatality. Better access controls, more effective training for the Technologists and anesthesiologist, storage to keep hazardous ferromagnetic materials out of sight, suitable portable cylinders, better QA/QC on the medical gas system… each of these might have been enough to avert this accident.

Add to this list the effective use of ferromagnetic detection, which might have provided the automatic feedback needed to sequester the fatal oxygen cylinder before the MRI exam even began, or remind the anesthesiologist of which materials were dangerous near the magnet, or provide warning feedback to the nurse who let herself into the suite.

As the Colombini accident illustrates, projectile accidents in the MRI suite are most often the result of multiple factors. Effectively interdicting these sorts of accidents requires vigilance on many fronts. While there are no ‘silver bullet’ solutions to MRI risks, no one product or training session that can eliminate the risks, there are products and solutions that help to minimize the risks. Most of the solutions have been around nearly as long as MRI, but only recently has ferromagnetic detection been added to the MR safety armamentarium.

This new ferromagnetic-only detection technology substantially increases the opportunity for Technologists and MR-staff to find and quarantine ferromagnetic threats worn by, or carried by, persons approaching the MRI magnet. In a forthcoming post I’ll describe the flurry of recent ‘best practice’ standards that all now call for the use of ferromagnetic detection to improve MRI safety.

Tobias Gilk, President & MRI Safety Director
Mednovus, Inc.
Tobias.Gilk@Mednovus.com
www.MEDNOVUS.com

UPDATE: Details of the finalized lawsuit settlement are available here.

One thought on “The Most Infamous MRI Accident: Colombini At Westchester

  1. Pingback: How To Spot A Psychopath :: Today, on "Surf-Celebrity Science Class"... :: March :: 2010

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