From the September 2012 issue of HealthCare Business News magazine


While severe, those accidents weren’t fatal. But fatalities, while very uncommon, do occur. Perhaps the best known MRI tragedy is the death of 6-year-old Michael Colombini in 2001. He was taken to a New York area hospital for a routine MRI test after having a brain tumor removed. An oxygen tank, mistakenly taken into the room, was attracted by the machine’s 10-ton magnet magnetic field, went airborne propelling through the air at 20 to 30 feet per second and fracturing the boy’s skull.

Gilk says this death could have been prevented too—from the technologist being more aware of the policies and procedures for MRI safety to not storing oxygen tanks in the hall across from the magnet room.


“I hate to say this, and I hope I’m wrong, but that accident could occur today. From a regulatory, accrediting, and licensing standpoint, we are in the exact same position,” says Gilk.

States leading change
A technologist needs to be able to control who goes in and out of the MRI environment, but more importantly, what goes in and out. In other words, the room that houses an MRI machine shouldn’t be like any ordinary room.

Roughly 20 states have adopted guidelines for design and construction of new health care facilities that have the potential to benefit patients and providers. The model code includes MRI safety and physical environment protections. It requires things like the ACR 4-zone principal, which says MRI facilities should screen patients for both clinical and physical risks before they’re brought into the magnet room, and that a technologist needs to have a line of sight to the entrance to the magnet room in order to monitor who’s going in and out.

The state requirements are not retroactive, so they don’t require health care providers who have an existing MRI room to go back and make the safety changes. “But at least going forward, it’s moving in the right direction and hopefully we can get other states to sign on,” says Gilk.

Joint Commission steps in
Unlike ionizing radiation modalities, many states are lax on what’s required regarding training and licensing for the personnel operating MRI machines.

“In many cases, the state licensures are minimal, sometimes all you have to have is an R.T. [registered technologist credential]; not even basic safety or special training for MRI,” says Gilk.

However, in the last six to nine months, the Joint Commission— which accredits the majority of U.S. health care facilities—has taken a new approach to safety training for personnel as well as other aspects of MRI safety. Gilk says he’s hearing instances where Commission inspectors are showing up at MRI facilities for surveys and specifically asking for documentation that staff have been trained in MRI safety in the last year. (Although training is not required by the ACR, it’s prominently featured in its guidelines on MRI safety).

September 2012 Magazine

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