Cal/OSHA investigated the Redwood City MRI accident that nearly killed an ICU nurse. The hospital received one citation. But the investigative file ran 327 pages—and buried inside were clues to a much bigger MRI safety story.

In this episode of The Invisible Force, John Posh and Tobias Gilk dig into the Cal/OSHA investigation of the 2023 Redwood City Hospital MRI accident, in which an ICU bed was pulled into an MRI scanner, pinning and seriously injuring a nurse.

The official Cal/OSHA citation focused on one hazard: the failure to keep the MRI scanner room door closed. But the agency's investigative file contained much more—employee interviews, MRI safety training materials, competency records, hospital policies, an internal incident report, and a physicist's evaluation performed just five months before the accident.

Those documents raise troubling questions. Why were the hospital's Level 1 and Level 2 MRI safety training programs essentially the same? Why did the MRI technologist have pages of documented competency assessments while comparable MRI safety competency documentation for the injured ICU nurse was absent from the Cal/OSHA file?

And then there's one particularly remarkable document: an MRI Safety Program Assessment Checklist completed five months before the accident that gave the hospital passing marks on every scored item.

How could an MRI safety program receive a perfect assessment—and months later experience an accident that nearly killed someone?

The deeper John and Tobias dig into the Cal/OSHA file, the bigger the question becomes: were the systems intended to identify MRI safety weaknesses actually capable of finding them before someone got hurt?

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Who was responsible for MRI safety at Redwood City Hospital when an ICU nurse was nearly killed by an MRI scanner?

In this episode of The Invisible Force, we take a deep dive into the CMS investigation of the 2023 Redwood City Hospital MRI accident—and uncover a disturbing question about who was actually responsible for keeping the hospital's MRI service safe.

The CMS report found problems ranging from the physical design of the MRI suite, to failures to follow established safety procedures, to serious questions about MRI safety training and emergency response. But as we follow the investigator's questions, another problem begins to emerge: MRI safety governance.

Who was the hospital's MRI Medical Director? The answer changed during the investigation. When investigators asked for documentation of the appointment, a department organizational chart appeared—with the MRMD and MRSO designations handwritten onto it. When they asked for documentation of MRI-specific training, the hospital could not provide it.

And then there's the decision that became critical during the accident itself: who had the authority to order a quench of the MRI magnet?

Using the CMS Statement of Deficiencies and Plan of Correction, we examine what the investigation revealed about MRI safety policies, ferromagnetic detection, Level 2 MRI safety training, MRMD and MRSO responsibilities, emergency response, and the systems intended to protect patients and healthcare workers from MRI accidents.

The story raises a larger question: Was this simply a series of individual mistakes—or evidence of a much deeper failure of MRI safety systems?

And importantly, the CMS report also provides something hopeful: a roadmap of changes that could make MRI accidents like this preventable.

Next: the OSHA investigation reveals an even deeper documentary record of what Redwood City Hospital taught its employees—and what they actually knew.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

The MRI accident nearly killed a nurse. But in the days afterward, it seemed as if almost nobody wanted to talk about it.

When The Invisible Force began investigating the 2023 MRI accident at Redwood City Hospital, the story was strangely absent from local news—even though photographs of the ICU bed stuck to the MRI scanner were circulating through professional radiology communities.

Hospital employees and other sources described a climate of silence. Then we discovered something even more troubling: a previous MRI projectile accident had apparently occurred at the same hospital—a ventilator pulled into the MRI scanner. What had been learned from that earlier warning? We couldn't find out.

So we turned to California's Department of Public Health.

And that's when the investigation took an unexpected turn...

The state health department appeared not to know about the nurse who had nearly been killed. Our call became the first indication that the accident had occurred at a hospital under its jurisdiction. The complaint was subsequently forwarded to the Centers for Medicare & Medicaid Services (CMS)—and CMS didn't simply pass it back to the state to handle.

CMS initially classified the incident as “Immediate Jeopardy."

What does that mean for a hospital? What happens when CMS determines that an MRI safety failure represents an immediate threat to life or safety? And what does a hospital have to do to avoid losing its Medicare and Medicaid reimbursement?

In this episode, The Invisible Force follows the investigation from the hospital's silence to federal regulatory scrutiny—and begins uncovering the MRI safety failures, corrective actions, and unanswered questions that would lead us toward separate CMS, OSHA, and California investigations.

This is the story of what happened after the MRI accident—and how much more there was to uncover.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

A botched patient transfer. A nurse new to the hospital. An MRI technologist trying to recover a schedule already thrown into chaos. Then, in less than a second, a 500-pound ICU bed became a missile!

In the Season Three premiere of The Invisible Force Podcast, we investigate the 2023 MRI accident at Redwood City Hospital in California—an incident that left a nurse critically injured after a motorized ICU bed was pulled by an invisible force into an MRI scanner. Through public records, government investigations, hospital policies, and firsthand sources, we reconstruct the chain of events that transformed an ordinary morning into one of the most significant MRI safety accidents in recent history.

Rather than focusing on a single mistake, this episode follows the decisions, communication breakdowns, workflow pressures, and human factors that quietly accumulated throughout the morning—until the powerful magnetic field of the MRI scanner turned a routine hospital bed into a life-threatening projectile hazard.

In this episode, you'll hear:

• A minute-by-minute reconstruction of the Redwood City MRI accident

• How communication failures between the Emergency Department, ICU, and MRI staff set the stage for disaster

• The split-second decisions made by MRI personnel during the emergency

• The controversy surrounding emergency MRI quench procedures and staff authority

• The devastating injuries suffered by the ICU nurse trapped against the MRI scanner

• Lessons every MRI technologist, nurse, radiologist, hospital administrator, and patient should understand

MRI exams are performed millions of times every year and are considered among the safest medical imaging procedures. Yet the invisible magnetic forces that make MRI possible can also become deadly when safety systems, communication, and training fail.

This episode begins a multi-part investigative series examining not only what happened inside Redwood City Hospital, but why the conditions that made this accident possible may exist in hospitals and imaging centers across the United States.

Topics: Redwood City MRI accident, Kaiser Permanente MRI accident, MRI safety, MRI projectile accident, ICU bed pulled into MRI scanner, MRI quench procedures, MRI technologist responsibilities, hospital safety, patient safety, medical imaging, healthcare investigations, MRI magnetic field hazards, radiology safety, hospital risk management, and MRI accident prevention.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Twenty-five years ago, the death of six-year-old Michael Colombini in a tragic MRI accident shocked the radiology world and forever changed how healthcare professionals think about MRI safety. The accident inspired the American College of Radiology's first MRI safety guidance, launched the modern MRI safety movement, and transformed best practices around the world.

But here's the question nobody seems willing to answer:

If we now know how to prevent most MRI accidents, why aren't those safety practices required?

In this MRI Safety Week special, The Invisible Force Podcast concludes its three-part investigation into the 2001 Michael Colombini MRI accident by examining the extraordinary legacy it left behind. We trace the creation of the ACR White Paper on MR Safety, the evolution of the ACR Manual on MR Safety, and how one devastating event became the foundation of modern MRI safety practice.

But the story doesn't end there.

Through an investigation of CMS requirements, Joint Commission standards, MRI accreditation programs, and state oversight, we uncover a troubling reality: despite decades of progress in MRI safety knowledge, many of the most important MRI safety practices remain recommendations rather than enforceable requirements.

In this episode:

• The Michael Colombini MRI accident and its lasting impact

• The origin of MRI Safety Week

• How the ACR White Paper on MR Safety was created

• The evolution of the ACR Manual on MR Safety

• MRI accreditation and Joint Commission standards

• CMS requirements for MRI patient safety

• Why MRI safety regulations remain surprisingly weak

• The gap between MRI safety best practices and enforceable rules

• What hospitals, imaging centers, regulators, and patients need to understand

Twenty-five years after the most influential MRI accidents in history, the MRI community possesses an extraordinary body of safety knowledge. The question is whether anyone is willing to require it.

Whether you're an MRI technologist, radiologist, healthcare leader, patient-safety advocate, policymaker, or patient, this episode explores one of the most important unanswered questions in modern medical imaging.

Topics: Michael Colombini, MRI Safety Week, MRI safety standards, MRI regulations, MRI accreditation, ACR Manual on MR Safety, CMS Conditions of Participation, Joint Commission MRI standards, MRI accidents, patient safety, healthcare regulation, medical imaging safety, MRI technologists, radiology policy, and MRI risk management.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

A six-year-old boy survives brain tumor surgery and is preparing to go home. Then a routine MRI turns into one of the most infamous accidents in medical history.

In this episode of the Invisible Force podcast, we continue our investigation into the mystery of the 2001 MRI accident that claimed the life of Michael Colombini at Westchester Medical Center in New York. After an oxygen system failure inside the MRI suite, a steel oxygen cylinder was brought into the scanner room and was violently pulled into the MRI magnet, striking the young patient and triggering a tragedy that would permanently change the conversation around MRI safety.

In our documentary style, we examine the frantic effort to rescue Michael from the MRI scanner, the hospital's public response, and the national media coverage that followed. We also explore the New York State Department of Health investigation, the role of hospital leadership, and the extraordinary statement by Westchester Medical Center CEO accepting responsibility for the care of the hospital's patient.

The second half of the episode follows the Colombini family's wrongful death lawsuit against the hospital, physicians, MRI personnel, and MRI manufacturer GE Healthcare. Through court records and legal filings, we explore how the case shaped understanding of MRI technologist responsibilities, physician oversight, hospital liability, medical negligence, and MRI safety standards.

This episode also examines how one of the most significant MRI accidents ever recorded helped drive the creation of modern MRI safety guidance, including the work that would eventually lead to the American College of Radiology's MRI safety framework.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

The O.G. fatal MRI accident - that reshaped MRI safety best practices around the world - happened in 2001 at Westchester Medical Center in New York. This second series from Invisible Force takes you back to that accident, recreating the accident that wound up killing six-year-old Michael Colombini. While many in radiology know the headline of the most infamous deadly MRI accident, surprisingly few know what happened or what went wrong on this, the 25th anniversary of the incident.

This episode tells the story of how the young boy found himself inside the MRI scanner, and the sequence of events that turned what would have been a miraculous diagnosis and surgery into a tragedy that snuffed out Michael Colombini’s life.

The next two episodes in the series will look at the near-term implications, including the New York State Department of Health (NYSDOH) investigation into WMC and the lawsuit, and then the longer-term fallout from this accident that shocked the conscience of the radiology profession, looking at the development of best practices and the sorry state of MRI safety licensure or regulation minimums. Please subscribe to make sure you don’t miss a single episode!

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

In July, 2025, Keith McAllister died in an MRI accident at Nassau Open MRI that was both anticipatable and preventable. What has the State of New York done in the intervening year to make MRI safer in their state? This episode tries to answer that question, and gives you a sneak-peek at our upcoming episodes.

The New York State Department of Health gaslit our hosts, pretending there was an investigation into the fatal MRI accident when there wasn’t one. When pressed on these details, they froze us out, so we resorted to a Freedom of Information Law request. After almost six-months, they finally responded to our request on what the state is doing to provide some minimum level of MRI safety to New Yorkers…

Despite reports of ‘following the events,’ and ‘ongoing investigations,’ and ‘attention to safety,’ we can’t say what – if anything – the NYSDOH is doing to help make MRI scans safer for New Yorkers. We can say, however, that Invisible Force will be doing new series on the MRI accident at Westchester Medical Center in which Michael Colombini died, as well as one on an accident at Redwood City Hospital where a nurse was trapped against an MRI scanner by an ICU bed.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

All of these agencies and organizations promise to ensure quality & safety of medical care… do they actually do this for MRI safety? And if they don’t, what can we do to help make sure that the people we love are getting MRI exams at places that take our safety seriously?

In this episode our hosts change the focus from the MRI death of Mr. Keith McAllister and Nassau Open MRI to each of us, and what we, as MRI patients, can do to help protect ourselves or our loved ones, helping to assure MRI safety at the hospital or imaging center where we seek care.

Are the signs from MRI state licensure, or MRI accreditation, that are good indicators for us to find safe MRI providers? Should we be getting our MRIs at hospitals instead of outpatient imaging centers? Should we only be going to MRI providers who have MRI safety officers (MRSO) on staff?

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

OK, it was a horrible MRI accident, but does that mean that there’s no accountability? In this episode our hosts break down the errors they’ve seen, as well as offering their takes on what they believe both civil and criminal liabilities might be.

In this episode our hosts, John Posh and Tobias Gilk, put on their pretend lawyer or MRI expert witness hats and discuss what legal duties or liability might be shouldered by Nassau Open MRI, the radiologist, and the MRI technologist. The hosts find that all three had duties to MRI safety that appear to not have been met, creating potential civil liability.

The host pair also look into New York criminal law, identifying whether there’s sufficient information to consider charging the three with criminally negligent homicide for the MRI death of Mr. Keith McAllister.

Created and written by: CAIREreporting.org and Tobias “Toby” Gilk

Hosted by: Tobias “Toby” Gilk and John Posh

Music & Art: Reggie Battle

Production: Multitude

Website: InvisibleForcePodcast.com

See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.