MRI Root-Cause Analysis (Twentieth Anniversary of Colombini Accident)

In order to recognize MRI safety weaknesses at any given site, you have to study how MRI accidents and injuries occur. Anybody with a printout of accreditation standards can be a mock-surveyor and run through a checklist, but does that person know if the checklist really represents MRI safety risks, or just check-boxes?

This year, 2021, is the twentieth anniversary of the most infamous MRI accident in the United States, the death of Michael Colombini. Ten years ago, in 2011, GRC founder Tobias Gilk collaborated with Robert Latino to develop a comprehensive analysis and root-cause investigation to identify not only the immediate proximate cause of the young boy’s death, but dug deeper to identify the structural, operational, and cultural contributors to this tragic watershed moment.

This root-cause analysis produced a couple of articles and presentations, a shortened version of which was recorded for YouTube. If you’re in MRI and you’ve never looked up the details surrounding that accident, you owe it to yourself to do so…

This intimate knowledge of how MRI accidents occur and the weaknesses at multiple levels that make tragedy possible is part of what makes GRC good at helping clients strengthen their MRI safety programs. It’s not about clipboards and checklists… it’s about each individual site’s practices and how well they match up with the unique site needs and industry standards for MRI safety.

The fact is, at the level at which they’re typically looked at, many MRI safety requirements for licensure or accreditation are purely performative. If your site counts on the provisions of your accreditation (whichever accreditation organization(s) your site is accredited by) as some sort of promise that you’re meeting best practices for MRI safety, you’ve been misled.

If all you want is someone to verify the operational elements for an upcoming accreditation review, you want a mock surveyor (and there are plenty of those). If you want someone to help you identify the potential landmines hidden in your operation -weaknesses that could prove catastrophic in the wrong situation- then you want someone who has studied the elements of MRI safety failure. You want someone who has helped providers disassemble and reassemble their MRI safety practices, to great benefit.

Click for more information on the range of available MRI safety consulting services.

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