Learning from 6 year old Michael Colombini’s Tragic MRI Accident

“This presentation will focus on the tragic death of 6 y/o Michael Colombini who was unnecessarily killed as a result of a series of errors while getting a routine MRI scan. This is a landmark case that involves many different entities and a multitude of presumptions and miscommunications. MRI safety even today is not regulated to the degree that it incorporates established best practice, much less to prevent future such accidents. Toby Gilk is a world-renowned expert in MRI safety and lobbies for increased protections to protect patients like Michael.
Ironically, the beginning of MRI safety is with a CT scan. Due to a fall Michael took on his school playground, he was given a CT to check for skull fracture. The good news was that skull fracture CT was negative. The bad news was it showed a brain tumor. Almost immediately. The boy was admitted for neurosurgery to remove the brain tumor. Needing a baseline following the surgery to be able to check for recurrence, he was going to have an MRI scan just before being released and unfortunately, for any of you who know the name Michael Colombini, that MRI scan did not go well.
When we talk about this particular incident to radiology professionals, we ask them the same question, “What do you know about what caused this accident?” We usually get three or four answers like somehow that there was an oxygen tank, that a nurse was involved, that as a result, the boy died. Sometimes somebody knows the geography and knows that this particular accident occurred in New York.
Well, if the object is to improve MRI safety, presumably MRIs are not inherently less safe in the state of New York. So that's not an effective causal route. The fact the boy died, well, that's not a cause, that's effect. So that's not going to help us Presumably, the presence of a nurse in general is not terribly effective in terms of causation. So, we're left with the fact the oxygen tank caused this accident and that's what the industry has largely run with.
Now, because this case has been resolved in the courts, documents are available to look deeper into the realities of this incident. Court documents were made publicly available through the Westchester County Clerk's court. These documents include first person accounts from all of the key personnel, as well as some documentation about the specific conditions of the accident. And by putting these pieces of the story together, we're actually able to recreate and detail that's never been available before.
What happened in this particular accident, and the accident occurred at Westchester Medical Center? This presentation will analyze the truth about why Michael Colombini’s life was ended so early, and what has the MRI industry learned and done about it since? Perhaps most importantly, we’ll ask what sort of practice environment could prevent a similar accident and compare existing regulatory and accreditation minimums against conditions that could actually prevent recurrence.”

[@BGinRS]

I remember when this happened. Tragic.

[@Julio-xk5gl]

I know bro it was so tragic

[@Julio-xk5gl]

Why are their no comments

[@OharaLu]

Idk