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Hospital error leads to CT scan radiation overdoses in 206 patients


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Cedars-Sinai,CT scan,stroke,HäggströmHow well do hospital medical technicians know their equipment? Not well enough in the case of some health care workers at Cedars–Sinai Medical Center in Los Angeles, where 206 x-ray computed tomography (CT) scan patients were given eight times the normal dose of radiation during brain scans over an 18-month period. The Los Angeles Times reports today that the cause of the overdoses has been traced back to a mistake the hospital made resetting a CT scanner.

The problem began in February 2008 when the hospital began using a new protocol for CT brain perfusion scans, which expose the brain to radiation in an attempt to help doctors analyze disruptions in the flow of blood to brain tissue and diagnose strokes. This change involved resetting the machine to override the preprogrammed instructions that came with the scanner when it was installed, the Times reports.

"There was a misunderstanding about an embedded default setting applied by the machine," according a written statement issued by the hospital. "As a result, the use of this protocol resulted in a higher than expected amount of radiation." Eight times higher, to be precise.

The error went unnoticed until this August, when a stroke patient informed the hospital that he had begun losing his hair after a scan.

Concerned that this error might not be limited to Cedars–Sinai, the U.S. Food and Drug Administration (FDA) last week issued an alert to CT facilities, radiologists, neurologists and several other types of health care professionals to warn them of possible "widespread problems with CT quality assurance programs," meaning the problem might not be isolated to Cedars–Sinai’s equipment or this particular imaging procedure. The alert concluded, however, "While unnecessary radiation exposure should be avoided, a medically needed CT scan has benefits that outweigh the radiation risks."

General Electric, the manufacturer of the scanner, released its own statement Monday saying there were "no malfunctions or defects" of the machine, the Times reports.

©Mikael Häggström via Wikimedia Commons

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  1. 1. geauxp 7:01 pm 10/13/2009

    It happens to me all the time with the printers at work. I go to read the directions and it seems they’ve been loosely translated from another language. Difference is, i’m not giving radiation poisoning to someone who is already sick. Some Japanese survivors of Hiroshima may have lessened the radiation sickness with miso and seaweed soup and ume plum jam. I never go a day without but also have stopped getting teeth x-rayed.

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  2. 2. Frosty46 6:37 am 10/14/2009

    Hospital radiology techs are unsupervised at best and there seem to be no checks and balances.
    Also they suffer from great test results but no common sense syndrome in a very unusual degree.

    Link to this
  3. 3. MCMalkemus 6:37 am 10/14/2009

    Iatrogenic death is the leading cause of death in hospitals.

    Sad but true. How many times you see a nurse wash her hands between patients? Sometimes, not always.

    Better to stay home and try to get well sometimes.

    Link to this
  4. 4. quantum_flux 3:57 pm 10/14/2009

    Holy crap, is that an actual image of a brain going to mush?

    Link to this
  5. 5. zoe 7:29 pm 10/14/2009

    That is a series of slices can’t see the detail but that’s what CTs of brains look like.

    Link to this
  6. 6. MCMalkemus 2:21 am 10/15/2009

    Funny thought. Actually it is a 3D representation of brain ‘slices’. Stack them all up, and you have a complete brain. The ‘mush’ happens over time as the radiation OD ruins DNA, and the whole structure starts to break down

    Link to this
  7. 7. radicalgirl 11:19 am 10/15/2009

    Reply to Frosty46. It has been my expirience after many years working in an imaging department that your state ment is not true. In fact hospital radiology techs are quite well supervised and there are many and frequent and balances including but not limited to a state required physicist’s annual test to the scanner.
    Unfortunate that you think so little of this profession, hope you stay well.

    Link to this
  8. 8. radicalgirl 11:36 am 10/15/2009

    In response to Frosty46, I disagree with your statement. It has been my expirience after many years of working in Imaging Departments that hospital radiology technologits are very supervised and there are many and frequent checks and balances known as quality assurance. These scientific tests include but are not limited to a state required physicist’s annual test.
    It is unfortunate you have such a poor regard for this profession. I hope you stay very well.

    Link to this
  9. 9. radicalgirl 11:38 am 10/15/2009

    Reply to Frosty46. It has been my expirience after many years working in an imaging department that your state ment is not true. In fact hospital radiology techs are quite well supervised and there are many and frequent and balances including but not limited to a state required physicist’s annual test to the scanner.
    Unfortunate that you think so little of this profession, hope you stay well.

    Link to this
  10. 10. radicalgirl 11:44 am 10/15/2009

    I disagree with your statement, Frosty46. It has been my experience after working many years in Imaging departments that hospital radiology technologists are very supervised. There are infact many and frequent checks and balances known as quality assurance.These include but are not limited to a state required annual physicist’s test of the scanner.
    It is unfortunate you have so little regard for this profession. I hope you stay very well.

    Link to this
  11. 11. jpooche08 1:49 pm 10/19/2009

    Yes, I do agree with Frosty46 statement. Now in response to radicalgirl, the key word is "profession" so why shouldn’t professionals be acountable for their actions and handle their job in a professional manner? We all hope to stay well and be healthy but at times medical assistance is required and in most cases we pay for insurance to insure that we are better prepared in the time of medical needs.

    I have been admitted a fews times to several different hospitals and required x-rays as well as a CT scan was performed and not once did I see anyone else in the area besides me and a technician there has nevered been a supervisor present. The last incident occurred on July 22nd at Cedar Sinai and my husband noticed that the radiology/imaging department looked like a ghost ward sure it was in the early morning hours but….. .

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  12. 12. CTMGR 2:55 pm 11/28/2009

    TO EVERYONE, AND THEIR COMMENTS….. THE ACTUAL TRUTH…. I Have been a CT scan manager for over 20 yrs,
    (1) Machines DO get checked with QA EVERY day
    (2) Their are ALWAYS supervisory people on duty…
    including a Radiologist (MD) to give advice or guidence
    to a tech if needed!
    (3) And If what you are expecting is a supervisor standing
    in each radiology room, whether CT,Nuclear medicine,x-ray,
    ultrasound, MRI, Vascular imaging,Interventional imaging…..
    …. you get the picture… impractical… AND think about your own workplace, whatever you do, I dont think each and every worker in you jobplace has a direct supervison standing right beside EACH and EVERY person in the company … again
    impractical… so if I visited you at your workplace for your particular service and sis not see this supervisory person
    at your side, should I make the same assumption about your
    field…that you are not regulated or monitored in any way??!!
    This WAS a BAD mistake!! But to Rip a whole group of
    ( MANDATED FULLY LICENCED ) professionals is (in the eyes
    of fully knowledgable techs like myself ) is more irresponsible
    than this facility was!!!

    Link to this
  13. 13. rockyflatsgear 4:03 am 02/21/2011

    This unfortunately happens with state inspected & FDA approved medical CT equipment. New airport backscatter x-ray scanners made by AS&E use the same energy (125KV) as CT. Airport scanners ARE NOT under FDA nor are they inspected for dose. This is a health risk to the young, expecting mothers and people with certain genetic issues. Jeff Rocky Flats Gear USA mfg of radiation undergarments.

    Related SA story:
    http://www.scientificamerican.com/article.cfm?id=terrorist-trap-or-virtual-strip-search

    Link to this

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