2024 Community of Human and Organizational Learning 30th Annual Conference

MRI celebrates its reputation as 'the safe imaging option,' sometimes to its own detriment. In 2023, a hospital in a prominent healthcare organization experienced a catastrophic, near-fatal MRI accident, which almost evaded regulatory review. Thanks to public investigation records from both CMS and OSHA, a more comprehensive Root Cause Analysis could be done, illuminating failures in management & oversight, ambiguous lines of authority and responsibility, poor training, and normalization of deviance from safety practices. The analysis also suggests a hospital so wrapped up in its patient safety scores and confirmation-seeking that failed to identify longstanding weaknesses in their MRI safety.

This session identifies the specifics of what happened, highlighting the direct and indirect actions of each party, recreating the accident, including scaled representations of the MRI suite and animations of the events, pulled from the official accounts.

Then the presenters will share their RCA of the event, which breaks down the day’s activities to reveal latent, underlying causes and contributing factors, identifying the contributions of faulty training, failures of competency verification, lapses in oversight, and dangerous presumptions that regulatory or accreditation structures provided some assurances of MRI safety at the hospital.

Lastly, the presenters will share a series of identified remedial steps, applying to individuals, the hospital organization, and to the regulatory and oversight structures designed to provide assurances of minimum quality and safety. Without a complete feedback loop that breaks through the ‘safe imaging option’ bumper-sticker slogan and creates change, more accidents like this will happen in the future.