0:01

So M R I. Accidents then. And now let's start with then,

0:06

let's start at the very beginning. What a very good place to start.

0:09

We're gonna start with the mother of all M R I accidents,

0:14

the Michael Colombini accident. Now, if the name doesn't sound familiar to you,

0:18

that's okay.

0:19

You may be more familiar with it as the young boy who died when an oxygen

0:24

cylinder was brought into the magnet room.

0:27

What we're looking at right now is a floor plan of the facility where this

0:32

bellwether accident actually happened, right?

0:35

And if you're not familiar or not comfortable looking at architectural drawings,

0:40

this is essentially a one meter thick coronal slice through the building.

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And if that helps you sort of visualize the building,

0:47

that's exactly what a floor plan is.

0:49

So I'm gonna walk us through very quickly and not a whole lot of detail this

0:54

particular accident. So we're gonna start with the anesthesiologist. I'm just,

0:59

I'm dropping him in the M R I scanner room. That's where he winds up.

1:03

But he begins where the boy Michael Colombini, the blue star,

1:08

he's in the induction bay, right?

1:10

And the anesthesiologist gives him a sedative before bringing

1:15

him into the MRI scan room.

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In addition to the anesthesiologist and the boy himself,

1:21

we have two technologists on duty, one of whom is about to run the study,

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the other of which is doing post-processing from a previous study. Now,

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as I say, the anesthesiologist gave the boy a sedative.

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They move him into the M R I room.

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Now as they're moving him from the gurney onto the M R I exam table,

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he pushes through that first dose of herce and they give him a second dose and

1:45

then they put the nasal cannula on him and they're putting the top half of the

1:50

head coil on him, and he pushes through his second dose of ed.

1:54

And so they give him a third dose. At this point, the M R I technologist,

1:59

who is assisting with positioning, goes back into the scan room.

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The anesthesiologist is there waiting for the study to start and sees the

2:07

pulse ox beginning to drop.

2:10

It would appear that they've over sedated the boy and it's suppressing

2:14

respiratory function.

2:15

The anesthesiologist goes over to the wall outlet to adjust the flow

2:20

of oxygen going to the cannula, but there's no flow, there's no air,

2:25

there's no oxygen coming out of the wall outlet.

2:29

So the anesthesiologist knocks on the window and goes to the door.

2:33

Having called for the technologist, there was no intercom in this set up.

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The technologist comes around and says, what's up doc? What can I do for you?

2:43

The anesthesiologist says, you know, my patient is desatting.

2:46

The oxygen is not working. I need you to fix the oxygen. Now,

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this tech was a very new hire to the M R I facility,

2:56

and she knew that there was something odd about

2:59

The oxygen. It wasn't piped in from the main hospital central supply,

3:03

but she wasn't exactly sure.

3:05

So she went back to the more senior tech who was doing the post-processing.

3:10

And the more senior tech said,

3:11

this is something that's really important for you to understand how it works at

3:15

this facility. If you don't know, let me show you. Let's do this together.

3:20

So the two of them go into the equipment room or system component room of the M

3:24

R I,

3:24

where there's a bulk cylinder that feeds a line that goes through the wall into

3:29

the magnet room. And that bulk cylinder had run dry.

3:32

So more senior tech is showing the more junior tech how to go about

3:37

swapping out the bulk cylinders. In the meantime,

3:40

the patient's oxygen sat continues to drop and drop and drop,

3:44

and the anesthesiologist becomes more and more agitated and he's

3:49

at the door and he's yelling to the technologist who now are essentially in an

3:54

acoustically separated room and they can't hear anything that the

3:58

anesthesiologist is saying.

4:00

So they're oblivious to his increasing levels of agitation.

4:05

So he's yelling and yelling and yelling for oxygen and yelling and frustration

4:09

that the techs aren't responding to him. And in this moment,

4:13

a nurse who had left something in the department from a previous patient lets

4:18

herself into the M R I area,

4:21

and she hears the anesthesiologist calling for oxygen for this

4:26

desatting child.

4:27

The nurse remembers from her earlier trip down to M R I

4:32

that she saw portable cylinders. Where did she see them?

4:36

She goes into the induction bay and she sees a few

4:41

portable oxygen cylinders.

4:43

She picks one of them up and hands it to the radiologist.

4:46

The radiologist turns around, takes two steps into the room,

4:50

and the cylinder flies into the r i scanner where the boy is positioned,

4:55

strikes the boy in the head and face the injuries ultimately

4:59

fatal.

5:01

But the immediate reaction of the anesthesiologist and the nurse is they

5:05

call the code team.

5:07

Code team comes and sees this and they panic a little bit because while they

5:12

know how to treat trauma,

5:14

they don't know how to extricate the boy out of the MRI cause he's somewhat

5:19

pinned by the cylinder.

5:21

The code team actually calls a paramedic team who was responding,

5:26

dropping a patient off and together,

5:28

the code team and the paramedics and the anesthesiologist and nurse,

5:33

they extricate the boy and they're wheeling him to the er.

5:37

And at about this moment,

5:39

the two technologists appear from the equipment room and announced that

5:43

everything is fine because they've swapped the cylinders and now the oxygen is

5:48

working fine.

5:49

So if you want more information about a more in depth root cause analysis,

5:55

if you have your phone, shoot this

5:57

QR code. I've got a few more QR codes in the presentation.

6:00

Ask yourself in this particular story,

6:03

what were the contributors to this accident? Right?

6:07

Was it the training or the knowledge level of the anesthesiologist?

6:10

Were the training and the knowledge level of the nurse, was it the technologist?

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A lot has been made today of lesser staffing at the point of

6:20

care.

6:21

This was an instance where we had two technologists at the point of care and

6:25

this accident still occurred.

6:27

Was it a question of who had access to the M R I suite?

6:32

Was it a problem with the cylinders?

6:34

I would argue that each and every one of those elements actually plays a

6:37

contributing role.

6:39

And if you compare those elements to existing

6:44

licensure regulatory accreditation standards,

6:47

I think that you'll find that it would really not be that difficult to be in

6:52

full compliance with your state licensure requirements and perhaps your

6:57

enterprise or modality level accreditation minimum requirements and

7:02

still have this accident occurred. Again,

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we're gonna look at accreditation requirements specifically here a little bit

7:09

later in the presentation. That was in 2001.

7:13

That accident happened.