Re-Opening the Michael Colombini MRI Case Via RCA: https://lnkd.in/eC-k4pHC For those in the healthcare space, they may remember this landmark case. It involved 6-year old Michael Colombini who was getting an MRI as a baseline due to a serious brain surgery he had just survived. Unfortunately, a series of predictable errors queued up in a particular pattern that day, that ended up taking little Michael's life. While this was undoubtedly a horrible tragedy, what could have possibly permitted this to occur? As a result of lessons learned from this incident, has MRI safety improved? If not, why not? Tobias Gilk (International MRI Safety Advocate) and I teamed up to review this case using our #rootcauseanalysis approach to identify the many latent or systemic root causes. We are hopeful this will help to increase awareness of MRI Safety due to such lessons learned, and having others spread such learning. Thx to the Community of Human and Organizational Learning for the platform to present such a case study, and to help us increase awareness. If anyone is interested in having this entire logic tree in a PDF format, just DM me and put COLOMBINI LOGIC TREE in the subject line. I will send it to you. LaRhonda Julien Jessica Morgan #mrisafety #reliability #rootcauseanalysis
Learning from 6 year old Michael Colombini’s Tragic MRI Accident
https://www.youtube.com/
My friend was the surveyor on this case for TJC
Bob, the video of your analysis is a great RCA teaching tool. I’m glad you are making this material available. I encourage people to take advantage of the opportunity.
Principal at Prelical Solutions, LLC.
1moThx for the SHARE Kellye Mantooth RT(R)(MR), MRSO(MRSC), MRSE(MRSC) 👍🏻