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The hospital where a 6-year-old boy died in a freak MRI accident has been fined $22,000 for 11 safety violations, according to the New York State Department of Health.
The accident happened recently at the Westchester Medical Center in Valhalla, NY. As a 6-year-old boy was undergoing an MRI exam, a staff member brought a metal oxygen cylinder into the room. The machine’s powerful magnet pulled the oxygen tank through the air and into the machine, fracturing the boy’s skull. The boy was sedated when he was struck, says Edward A. Stolzenberg, president and CEO of Westchester Medical Center.
Stolzenberg says the hospital conducted an extensive root-cause analysis and identified a wide range of systemic failures, including poorly trained staff. The hospital instituted a number of policy and procedure improvements. (See the story in Healthcare Risk Management, October 2001.)
Robert Kenny, a spokesman for the health department, says the $22,000 fine is the maximum allowable under state law — $2,000 for each of the 11 violations. Kenny says the department hoped to bring attention to the seriousness of the safety violations by imposing the maximum fines.
The health department also criticized Westchester for not reporting or adequately investigating a similar accident in 1997. In that case, an oxygen tank struck the MRI machine but no patient was present. Kenny says a proper investigation of that incident may have prevented the fatality.
In addition to the fines, Westchester must submit a plan for correcting the deficiencies and the health department will conduct unannounced inspections.