REDWOOD CITY, Calif. - What was supposed to be a routine MRI scan quickly became a freak accident at a Bay Area hospital.
From the outside, it was an ordinary February day at Kaiser Permanente’s Redwood City Medical Center. But inside the MRI center, an MRI technologist had just finished a call and heard screaming coming from another room.
The hospital bed was pulled uncontrollably into the MRI machine by its magnetic force as seen in photos obtained by KTVU.
A nurse became pinned between the bed and the machine and suffered crushing injuries, according to an investigation by Cal/OSHA.
"I was getting pushed by the bed," nurse Ainah Cervantes told investigators in a report obtained by KTVU. "Basically, I was running backwards, If I didn’t run, the bed would smash me underneath."
Online videos show the sheer power of the machine’s magnet on anything metal. MRI safety advocates say projectiles, burns and implanted devices are common causes of MRI-related injuries and deaths.
Cervantes had a severe laceration that required surgery, which included the removal of two embedded screws, documents show. The patient who fell from the bed onto the floor at the time was not hurt.
Though the incident first occurred in February, the investigation was not completed until several months later.
MRI expert Tobias Gilk said the MRI machine does not stop being magnetically attracted once it hooks onto 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," he said.
Gilk’s research into MRI machine incidents includes federal data that shows as the number of scans and exams increases, so do accidents but at three times the rate.
(Picture of MRI accident that crushed Kaiser nurse Ainah Cervantes in Redwood City back in Februrary )
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."
Findings by the California Department of Public Health show Kaiser Redwood City "failed to provide radiologic services in a safe manner."
Regulators say the systemic problems at the facility started with the nurse and patient care tech left unsupervised without MRI personnel. No one, including the patient, was ever screened. The door to the magnetic room was left open. And the safety alarm system never sounded.
The state said it cannot speculate on how often incidents like this happen and admits there are no regulations to specifically address MRI centers.
"In order for us to run an MRI center safely, safety education is critical," said Dr. Emanuel Kanal, a radiologist at the University of Pittsburgh.
Kanal has studied hundreds of incidents and said safety training is vitally important. He stressed MRI personnel should have minimum standards just like airline pilots.
"Coming at it from an aviation safety point of view – standardization, certification, recertification, ensuring you’re on top of your game – to me, these are critical aspects of what we need in magnetic resonance to make sure we decrease these incidents as much as possible," Kanal said.
KTVU obtained Kaiser’s MRI safety policy and found several breaches, contributing to the accident.
The policy states employees are not allowed in the magnet area without the appropriate screening, gurneys and other metal objects will not be taken into the MRI room, and the door to the MRI room should be kept closed at all times.
Incident investigation records show some required safety training never happened for some employees and the facility also failed to test the door alarm annually as recommended.
The Department of Public Health’s investigation stated, "The many safety failures…created a culture of unsafe practices."
Kaiser Permanente declined an interview but responded in a statement.
"Our teams responded quickly and those involved immediately received the care and support they needed," said Sheila Gilson, senior vice president for Kaiser Permanente San Mateo area. "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."
But sources allege this wasn’t the only incident at the Redwood City hospital. A photo provided to KTVU shows a medical equipment cart stuck to the MRI scanner. Kaiser said it was likely from an incident in March 2015 where 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 said in a statement.
MRI safety experts told KTVU that without enough oversight or mandatory safety requirements, patients can be put at risk.
"It becomes important for us to ensure that we restrict access to the site only to people that need to be there," Kanal said. "We can control what and who enters and how they’re exposed to what."
Kaiser is facing an $18,000 fine from Cal/OSHA for the missteps and a workplace injury accident.
"It’s not just a failure of the last barrier or the last individual," Gilk said. "It’s a failure of many protections or preventions. My first thoughts were – not again."