Diagnostic disaster: Arizona woman receives 50mg diazepam instead of contrast media in MRI mishap

By Stephanie Srakocic | Fact-checked by Davi Sherman
Published February 12, 2024

Key Takeaways

  • An Arizona woman received 50 mg of diazepam instead of contrast media during an MRI.

  • This is the second serious patient incident reported at one of SimonMed Imaging Center’s Arizona locations.

  • SimonMed was operating in Arizona without a license from the state health department.

A woman received an excessive dose of the wrong medication during a 2021 MRI scan at Thompson Peak SimonMed Imaging Center in Scottsdale, AZ. An MRI tech administered 50 mg of diazepam instead of contrast media. The United States Food and Drug Administration (FDA) recommends a maximum of 10 mg of diazepam as a single dose. The high sedative dose immediately rendered the woman, who has not been named, unconscious.[][] 

Records show that the emergency room physician who later treated the woman expressed shock that she had received such an excessive amount of diazepam. He called Thompson Peak SimonMed to question the event, and they confirmed the dosage. The lawsuit against SimonMed alleges that the imaging center initially promised to pay the woman’s hospital bills but that they failed to do so. Additionally, the suit states that SimonMed has billed the woman for her incomplete MRI.[]

According to the court filing, the woman had to restart anti-seizure medications and delay her IVF treatments for one year following the diazepam overdose. SimonMed has acknowledged the medication error and overdose but has denied fault in the woman’s later medical developments.[] 

SimonMed Imaging has locations throughout the country, nearly 70 of which are in Arizona. Centers provide imaging services such as MRIs, ultrasounds, mammograms, CT scans, and PET scans, along with genetic cancer testing. 

Previous patient safety incidents

This incident isn’t the only time concerns about patient safety have been raised at SimonMed’s Arizona locations. In May 2022, a SimonMed MRI tech at SimonMed’s Avondale location told a corrections officer not to remove the metal shackles around Lacy Windust’s waist. The MRI machine pulled Windust by the restraint, causing her to become stuck to it. She required care at a local emergency room, where she received stitches for a cut on her hand and received care for multiple bruises. The corrections officer had his gun during the MRI and also became stuck to the machine.[]

In October 2023, local news station ABC15 discovered the company had been operating without a license from the state of Arizona’s Department of Health Services. SimonMed was initially a physician-owned company, allowing it to operate under a private office exemption from health department licensure.[]

However, as the company has grown, it has received large investments. The state reevaluated SimonMed’s private ownership status in late 2023. Currently, some of SimonMed’s Arizona locations have acquired licensure. All the company’s locations in the state are on track for licensure in the near future. This will put the imaging centers under the oversight of the Arizona Department of Health Services and allow the department to investigate recent incidents.[] 

Ensuring patient safety

It’s an easy argument to say that a provider is at fault when contrast media is switched for a sedative or when a patient is told to wear a large piece of metal inside an MRI. There are many more minor and more common missteps in patient safety. Not all of these mistakes will lead to direct patient harm or malpractice, but they will increase the risk of patient harm. 

Physicians who manage practices or have other healthcare professionals working under their direction have additional patient safety concerns to think about. Senior Patient Safety Risk Manager for The Doctors Company, the nation’s largest physician-owned medical malpractice insurer, Sue Boisvert, BSN, MHSA, says that physicians can take steps to ensure patient safety is a priority for all healthcare staff members. 

“Patient safety should be embedded in the culture of the practice from start to finish and must be supported by leadership. As leaders, physicians can nurture a culture of safety by establishing goals, fostering teamwork, and empowering staff to report safety issues without fear of reprisal or being blamed. Providers and staff should feel comfortable talking about safety and developing tools and processes to reduce the risk of adverse events and improve safety for everyone, including patients, staff, and physicians,” says Boisvert. 

Boisvert also says that every incident can be a learning opportunity for physicians and the healthcare team. 

“Investigating adverse events and errors for the root cause(s) of the patient harm is an excellent, retrospective way to evaluate safety practices. Near-miss events provide an opportunity to determine what went well,” Boisvert says. “What action or intervention occurred during the process that prevented the harmful event from reaching the patient, and how can that be leveraged to increase safety across the practice?”

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