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Radiation Overdose At One Hospital

Posted by Jane Akre
Tuesday, October 13, 2009 11:11 AM EST
Category: Major Medical
Tags: CT Scan, Cedars Sinai, General Electric, Stroke, Brain Perfusion

A CT brain perfusioin scan was set to the wrong radiation dose at Cedars Sinai Hospital in Los Angeles for 18 months.


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IMAGE SOURCE: Cedars-Sinai Hospital, Los Angeles Web site

It is a case of radiation overdose on more than 200 people that never should have happened.

After Cedars-Sinai in Los Angeles reset a CT scan machine in February of last year, patients receiving brain scans got more than eight times the normal dose of radiation, the Los Angeles Times reports.

The revelation of the error came to light when a patient reported that he began losing his hair after the scan.

After contacting 206 people who had the same procedure, the hospital learned that about 40 percent also suffered hair loss. Some also had a skin-reddening.

The mistake happened when the hospital began using a new protocol for a specialized type of scan - the CT brain perfusion scan - that allows doctors to diagnose the flow of blood to the brain following a stroke. To perform that scan, technicians had to override the pre-programmed instructions that came with the General Electric-made machine.

General Electric says the machine has no defects or malfunctions.

In a statement, the Los Angeles hospital says, "There was a misunderstanding about an embedded default setting applied by the machine . . . ," officials at the renowned Los Angeles hospital said in a written statement that provided no other details about how the error occurred. "As a result, the use of this protocol resulted in a higher than expected amount of radiation."

“The magnitude of these overdoses and their impact on the affected patients were significant,” the federal agency said, warning that undetected overdoses put “patients at increased risk for long-term radiation effects.”

Doctors sometimes override a scanning preset protocol to use less radiation. Any override is generally done at a larger hospital says Dr. Thomas Dehn, a radiologist at National Imaging Associates Inc, to the Los Angeles Times.

Each of the 200 patients receiving a CT brain perfusion scan was subjected to the overdose. Meanwhile the machine settings went unnoticed for 18 months. Other types of scans were also performed but the reset error affected only the potential stroke patients.

A CT scan uses a series of X-rays to create a highly detailed image. Possible stroke victims are injected with an iodine solution, which appears in the scans and is used to track blood flow in the brain.

For Consumers

It is difficult to know you are receiving excess radiation. More radiation produces a clearer image and this procedure uses more radiation than other types of CT scans.

A reaction such as hair loss or skin rash should be reported immediately. The Food and Drug Administration (FDA) has issued an alert warning hospitals across the country to check their CT protocols.

Excessive radiation exposure increases the risk of cancer. The average age receiving the CT scan was 70 so the risk is reduced as they are likely to die of other cause first. #

*Late Addition to Story*

Rick Patterson of Owen Patterson and Owen, an InjuryBoard member law firm from Valencia, California, confirmed that they represent some of the Cedars Sinai patients who are victims of the radiation overdoses that occurred over the past 18 months. One of the firm's clients was unfortunately subject to two CT Scans within a 7 month period. She is presently hospitalized and her prognosis is grim, the law firm says.

"Radiation is cumulative in the body and can be fatal," Owen, Patterson & Owen says in a statement.

General Electric ( GE), the CT scanner manufacturer, was quick to announce that the machine did not malfunction.

"Even if the machine did not malfunction, Patterson is concerned that there is no safety or warning system that would alert an operator when the prescribed exposure level is double or triple the normal setting. It is outrageous that it could be set 800% higher than the treating doctor ordered and there not be some built-in safety system.

"Something as simple as backing up a car is dangerous, but as simple as it may seem, there is a very effective warning system that beeps when one gets to close to another car.
had there been some simple warning system on this scanner, perhaps this healthcare catastophe could have been avoided.

"In addition to helping our clients through this we are also focused on forcing a change in the system that would prevent such egregious human error while operating this type of dangerous medical equipment," the statement says. #


2 Comments

Posted by Jane Akre
Thursday, October 15, 2009 1:44 PM EST

To make matters worse- the San Jose Mercury News reports that four patients were not even informed that they had been overexposed.

LINK

Anonymous User
Posted by Mariann Laws
Tuesday, October 20, 2009 12:02 PM EST

My husband, Percy Laws was a patient at Cedars-Sinai in March 2009. He had a brain CT scan. I was called in September- it was a very ambigious call. "Did he have hair loss?" etc. We have been through so much lately 5 months in hospitals-rehab. I wasn't thinking clearly-and the woman s
aid nothing about heavier than normal radiation.Just wanted to communicate, today, to see where we should go with this??
Thanks for any input.
Mariann Laws

Comments for this article are closed.

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