Did the MRI community learn from the Colombini tragedy?

Jul 27, 2005

It was four years ago this month that 6-year-old Michael Colombini died in the tragic MRI accident that has become the single greatest reference point for MRI safety. Word of the accident rolled like a grim tide over the professional radiology community in 2001 and forever changed the landscape of MRI safety -- or did it?

Many of us know what happened, but there has been surprisingly little written about why it happened.

Disaster strikes

The young boy was anesthetized while receiving an MRI at Westchester Medical Center in Valhalla, NY. At some point during the scan, Michael required supplemental oxygen from the system built into the magnet room, though the oxygen system failed to work properly.

The MRI suite was a modular building that had been attached to the hospital. Though provided with oxygen service, the medical gas did not come from the hospital but was fed from an independent tank. This independent oxygen service didn't have a zone alarm tied into the central system, so when there was a problem with the MRI room oxygen supply, nobody outside of the immediate MR suite was aware of it.

The suite was staffed with two technologists. Both reportedly left the control area to attend to the oxygen supply problem, leaving the anesthesiologist in the magnet room, screaming for oxygen for the boy. At some point, a hospital staffer grabbed a portable oxygen cylinder from the control room and brought it into the magnet room where, because it was ferromagnetic, it was grabbed by the magnetic force and impelled into the bore of the MRI, striking Michael Colombini in the head and killing him.

'Missile effect'

Several factors contributed to this first known "missile effect" death: poor planning, improper suite design and construction, failed maintenance, a lack of training on safety procedures, improper materials screening, failed segregation of nonsafe tanks, and the loss of the only remaining safety control present -- the technologists. Apart from the need for continual staff safety training, the contributing factors to the death of Michael Colombini get very little attention in many contemporary MRI safety conversations.

So in the intervening years what have we done about medical gas requirements for MRI facilities? What are the mandates for centralized zone alarm systems? Who enforces MRI safety training standards? What suite access controls are now required to prevent the untrained from entering? What about equipment screening and segregation?

Nothing. None. Nobody. None. Nothing.

For all our talk about MRI safety, we continue to dishonor the tragedy of this MRI death by failing to both understand why it happened and, ultimately, failing do something about it.

In no way should this be considered a slight against the American College of Radiology's (ACR) "White Paper on MR Safety," or the extensive work of MRI safety experts, Dr. Emanuel Kanal and Frank Shellock, Ph.D.

But as the events in the Colombini tragedy show us, not all MRI safety is clinical safety. The 2004 "Updates and Revision" to the original ACR paper acquiesces to this fact, acknowledging that the new additions "do not attempt to deal with all aspects of MR safety, but rather with those that apply to already installed, active sites."

Without question, safe clinical practice requires the continual development of information about implant safety, conductive-lead positioning, RF heating, SAR concerns, and contrast agents, among many other issues. But we need to recognize that for all our work in the clinical side of patient safety, we have neglected many of the root causes of this accident. The Colombini accident may have galvanized us, providing a rallying point for clinical MRI safety, but we have extracted very few of the lessons from the tragedy and we are very far from applying them on a broad scale.

We can measure just how far we have yet to go by reviewing the most current designs for MRI facilities proposed across the U.S. MRI suites continue to be designed and built with profound failings in patient safety. Issues as elemental as the technologist's view of the magnet room door, patient screening, and access controls are conspicuously absent from many contemporary MRI suites. In fact, there is little in terms of patient safety protections that could distinguish a 10-year-old MRI suite from a typical 2005 design.

Even for those who wish to design a safer MRI facility, it is far more difficult than it ought to be. Short of the rudimentary suite diagrams provided in the two releases of the ACR white paper, no professional body within the last four years has promoted the information needed to enable facilities and their designers to provide safer and more effective MRI environments. This includes the Food and Drug Administration, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO), the American Institute of Architects (AIA), and all fifty state departments of health.

Without additional guidance, departmental planners and architects are left to their own devices, extracting lessons from the ACR white paper and superimposing them on MRI vendor-supplied templates. This cut-and-paste remedy is a dismal substitute for the sort of comprehensive safety that should be commonplace in our MRI facilities.

This week it is particularly appropriate for us to pause and remember the young boy's death. But if that is all we do, then we again fail to appropriately learn from this tragic accident.

Michael Colombini's death may not have changed the course of MRI safety as many had hoped, but it's not too late. We can deconstruct the accident and develop effective requirements for MRI facility safety. The information is available and only just waiting for us to apply it. The alternative is for us to continue with the status quo, and hope that the next person tragically injured in an MRI accident is more effective at motivating us to change.

By Tobias Gilk
AuntMinnie.com contributing writer
July 28, 2005

Tobias Gilk is an architect with Jünk Architects in Kansas City, MO. He is co-editor of the "MRI Newsletter" available from www.MRI-Planning.com.

MR safety versus the bottom line: Why safety pays, June 16, 2005

The 3-tesla MRI swap: Why it's not a simple upgrade, January 27, 2005

The fire extinguisher in your MRI suite: will it save a life or take one? September 24, 2004

MR accident results in child's death, July 31, 2001

The opinions expressed in the guest editorial are those of the author, and do not necessarily reflect the views of AuntMinnie.com.