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SPIn July 2001, 6 year old Michael Colombini from Croton on Hudson, New York, went to Westchester Medical Center in Valhalla for a routine follow up MRI scan after doctors had successfully removed a benign brain tumor. He was sedated and placed inside the MRI machine while doctors monitored him during the procedure. During the scan, medical staff noticed that his oxygen levels were dropping and the oxygen supply connected to the MRI room was not working properly, prompting doctors to urgently call for additional oxygen.
As staff tried to respond quickly, a portable oxygen cylinder made of ferrous metal was brought into the MRI suite. MRI machines contain extremely powerful magnets that are always active, and when the tank entered the room the magnetic field immediately pulled it out of the anesthesiologist’s hands and across the room at high speed. The tank was pulled directly into the scanner where Michael was lying, striking his head and causing a severe skull fracture and traumatic brain injuries.
Michael Colombini passed away two days later from blunt force trauma caused by the accident. The tragedy shocked the medical community and became one of the most widely cited MRI safety incidents in history. Investigations revealed multiple safety failures and the case eventually led to a lawsuit by the family, which resulted in a $2.9 million settlement with the hospital. Today, the Colombini case is still taught in radiology and hospital safety training as a reminder of the dangers of bringing metal equipment into MRI rooms and the importance of strict safety procedures
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