A woman undergoing an MR scan at an Arizona-based SimonMed Imaging center was allegedly given valium instead of contrast media at five times the recommended maximum dosage, exacerbating her existing medical conditions and leading to new ones.

In a medical malpractice suit, attorney Rachel Fitzpatrick says a tech at Thompson Peak SimonMed Imaging Center in Scottsdale erroneously injected her client with 50 mg of diazepam (Valium), leading her to be admitted to the ER. The patient’s medical records say the same, with the ER doctor writing that “to provide 50 mg of Valium, the nurse would have had to draw up medication from a large number of vials, which would be a highly atypical practice.”

SimonMed admitted the patient was mistakenly provided Valium but denied the other allegations, reported ABC15. In a statement, it said that it investigates all incidents but that HIPAA laws prevent it from sharing any details.

“We prioritize patient well-being and safety above all else. We adhere to strict regulatory requirements and guidelines and strive to continually ensure that our employees are properly trained to handle all possible patient and care-related situations.”

Fitzpatrick says the error and overdose forced her client to go back on antiseizure medication and delay IVF fertility treatments by a year. The patient asked ABC15 for anonymity to protect her privacy.

“There are procedures, or there should be, that are in place to ensure that this precise thing doesn’t happen,” said Fitzpatrick.

A day after the procedure, the patient recorded a phone call with a SimonMed employee who admitted that a “big error” was made and said the company would cover her hospital bill. Fitzpatrick says that SimonMed failed to do this and sent her client a bill for the incomplete MR scan.

An ABC15 investigation in 2020 revealed that the company was unlicensed and that the state health department did not regulate it due to a private office exemption. This, it said, prevented the company from being held accountable in another incident in May 2022 where an Arizona inmate became stuck to an MR scanner because a SimonMed tech told the prison guard not to remove the shackles around her waist. One guard who had a gun on him also became stuck. The inmate required stitches for a deep cut on her hand and was left with bruises and an imprint from the shackles.

According to ABC15, 11 SimonMed Imaging centers are now licensed by the state health department, and soon, all Arizona locations are to become licensed as well.

Medication errors are one of the most common causes of adverse events. Nonprofit medical safety organization ECRI listed such incidents as the third-highest on its list of top 2024 health tech hazards, saying that they are primarily due to hospitals and providers disengaging technology safeguards and modifying EHR systems to work in ways that best meet their needs, sacrificing safety and ease-of-use in the process.

In a similar scenario to the one in Scottsdale, a 75-year-old woman at Vanderbilt University Medical Center died in 2017 after being given a paralyzing agent instead of a sedative for a PET scan. The nurse who gave her the medication, RaDonda Vaught, disengaged a computer safeguard, leading to the mistake. She was convicted of negligent homicide and abuse of an impaired adult and given three years probation. The case has raised concerns about the prevalence of medication errors and debates on holding nurses and other medical practitioners responsible.