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Thu Oct 15 01:34:16 BST 2009

The story below was released on CNN  yesterday.     I was with a doctor 
from the specific  hospital under investigation later in the day and the story 
was  confirmed.    I have confirmed the story now from at least 5  sources.  
 The exposure was up to 8 times the recommended dose for the  condition for 
which the CTs were being ordered.    This is a  matter of the technician 
and supervising radiologist making the appropriate  calculations and 
oversight.     There but for the grace of  God are all of us.      I did ask 
radiologist and  radiation safety officers just how often this kind of over 
calculation might  actually happen.   I will not quote what I was told, but this is 
NOT a  fickle issue.    There is NO question that far too many CTs are  
being ordered.   There is NO question that many physicians who order  CTs only 
review the reports and not the actual image.   There is NO  question that 
many over readings and terminology to cover ones backside are  often cited on 
many images.   There is NO question that initial  readings are frequently 
re-written after further review and the original  dictation mysteriously 
disappears.    There is NO question that  many VOMITs are being dictated as I am 
aware of many cases where operations were  not performed because of the CT 
reading in patients who needed an operation and  likewise operations were 
performed on the basis of the CT, when no pathology at  all was found at 
surgery.       We have already  had our first case of lymphoblastic leukemia in a 
patient with significant  radiation dosage from CTs, arteriograms, and other  
imaging.     
Some persons were concerned that I shared this investigation with  you.   I 
am aware that regulatory agencies have alerted their field  representatives 
to specifically look at the dosing from CTs and the record  keeping.    I 
will repeat, "A word to the  wise.....".     Each of us will be asked to show 
that we are  monitoring the dosing from imaging from CTs, IR, and other 
arteriography  etc.     

If you think that this story out of California is trivial, just  check with 
your Radiation Safety Officer.   

k

Radiation Overdoses At Cedars-Sinai Prompt Investigation

1:57 pm  
October 14, 2009  
_comments  (0)_ 
(http://www.npr.org/blogs/health/2009/10/cedars_sinai_ge_found_to_be_be_1.html#commentBlock)  
_Recommend (6)_ (javascript: NPR.community.recommendStory();) 

byline goes here 

By Maggie Mertens 
Only after a patient complained in August about losing some hair following 
a  CT scan did Cedars-Sinai Medical Center realize more than 200 people had 
been  exposed to excessive radiation from diagnostic tests performed there 
in the last  year and a half.  

Cedars-Sinai Medical Center in Los Angeles, where more than 200 patients 
were  exposed patients to excess radiation during CT scans. (Ric  Francis/AP)

We first heard about the problem, involving doses  as much as eight times 
normal, when the Food and Drug Administration issued a _cryptic  warning to 
hospitals_ (http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices
/ucm185898.htm)  last week, urging them to be on guard for excessive  radiation 
doses from CT scans for stroke.  
But the advisory didn't name the hospital or maker of the scanner involved. 
 General Electric made the scanner, we later learned.  
Now we know those details, but we still don't have a definitive answer on 
how  a scanner being used to diagnose strokes delivered enough radiation to 
redden  skin and cause hair loss in some patients. The FDA told us today that 
it's  continuing to investigate both user errors and the scanner itself.  
So far it looks as if the CT scanner operators at  Cedars-Sinai failed to 
heed notices of jacked-up radiation doses after  technicians reprogrammed the 
machine and overrode standard settings, the Los  Angeles Times _reported_ 
(http://www.latimes.com/news/local/la-me-cedars-sinai14-2009oct14,0,5065886.st
ory?page=2) .  The overdoses carried a 1-in-600 lifetime risk for causing a 
brain tumor,  according to an outside doctor's calculation cited by the 
paper. 
For its part, Cedars-Sinai says it has put in place double-checks to make  
sure the problem doesn't happen again. And the hospital continues to probe 
how  the situation persisted for 18 months unnoticed. 
GE has stated the excess radiation wasn't its fault. "There were no  
malfunctions or defects in any of the GE Healthcare equipment involved in the  
incident," they told us in a statement. 
Back in August we _reported  how more and more people_ 
(http://www.npr.org/blogs/health/2009/08/heart_stress_tests_pump_up_rad.html)  are being exposed 
to high doses of radiation  through common medical tests, even when 
performed properly. If you're concerned  about radiation from scans, talk over the 
risks and benefits of the tests with  your doctor. 
categories: _Hospitals_ (http://www.npr.org/blogs/health/hospitals/)  

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Cedars-Sinai Under Investigation for CT Radiation  Overexposure to 206 
Patients 

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Cheryl Clark, for HealthLeaders Media, October 12,  2009

The 206 people who received "significant" overdoses of radiation eight 
times  above expected levels were undergoing CT scans for detection of stroke at 
Cedars  -Sinai Medical Center in Los Angeles, federal and hospital 
officials confirmed  on Friday. 

The incidents, which may have occurred over an 18-month period starting in  
February 2008, is under investigation by California public health officials 
and  the U.S. Food and Drug Administration. 
The multi-slice CT scanner involved was manufactured by GE Health Care, 
said  Mary Long, spokewoman for the FDA. "We are evaluating information to 
determine  if this is a more widespread problem with CT protocols and not 
limited to one  facility or scan," she said. The FDA wants hospitals that may have 
had similar  problems with such scans to file a voluntary report to the 
agency's _Medwatch Web site_ 
(http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm185898.htm) . 
"We are collecting information from the manufacturer and the facility  
relating to both the equipment and its use," she added. 
Sandy Van, spokesman for Cedars-Sinai, said the problem was noticed in 
August  2009, "when a patient who had previously received a scan contacted the 
medical  center after noticing temporary patchy hair loss. 
"Since this is not a common side-effect from CT brain perfusion scans,  
Cedars- Sinai immediately began an investigation of the equipment involved and  
the protocols used for CT brain perfusion scans," Van said in a statement. 
"No  additional CT brain perfusion scans were done until the investigation 
was  completed." 
Van did not answer a question about how many patients had experienced  
symptoms linked with radiation overdose, but according to a Los Angeles  Times 
article on Saturday, a hospital spokesman said about 40% of the  patients 
lost patches of hair as a result of the overdoses. It is unclear why  the 
problem with the scans was not recognized until August. 
GE Healthcare said in a statement "there were no malfunctions or defects in 
 any of the GE Healthcare equipment involved in the incident." 
They emphasized that "patients and families should continue to have  
confidence in their doctor's recommendation for a CT scan." 
Also, the company said GE "continues to offer dose-reducing technologies 
and  expand key CT training initiatives to raise awareness of dose 
optimization and  use of appropriate exam protocols. 
"GE Healthcare CT products require that: 1) users carefully evaluate  
user-defined scanning protocols against the validated protocols that are  
provided on the scanners during installation, 2) like dose recommendations for  
drugs, the recommended dose for a prescribed medical imaging scan is an  
important clinical decision that should be made by a licensed professional in  the 
context of healthcare delivery." 
The investigation revealed that some scans "were delivering a higher dose 
of  radiation than anticipated, which could cause temporary hair-loss or  
skin-reddening in some patients," Van said. 

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_More  People Are Living With, Not Dying From, Hip Fractures_ 
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First, the good news. The percentage of the population  suffering hip 
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Patients who do fracture their hip and live to tell about it... 

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Hospitals seeking to reduce their operative complication  rates should make 
sure their attending surgeons get at least six hours of sleep  between the 
time they last performed an operation, according to a study. 

_Cedars-Sinai  radiation overdoses went unseen at several points_ 
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Beginning in February 2008, each time a patient at  Cedars-Sinai Medical 
Center in Los Angeles received a CT brain perfusion scan,  the dose displayed 
would have been eight times higher than normal. No... 

Book: _National Patient Safety Goals Calculator 2009_ 
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The National Patient Safety Goals Calculator, 2009:Tools  to Assess 
Compliance is a series of highly interactive tools that bring  department leaders 
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