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Thu Oct 15 03:45:51 BST 2009

I agree with what Ken has said about over ordering of CT's an other studies; providers looking only at the reports and not actually viewing the images themselves; management decisions being made by a non clinician (radiologist) without cross checking the images by the clinician; routine ordering or CT (and other tests) on trauma patients; and lack of proper documentation of the need of a procedure. I pointed this out on a recent posting of the fight that had to prevent the non surgical clinicians when I did not want to order a CT on a gunshot chest when the management was obvious on a plain radiograph.

I expect that most of the readers of this list serve have many examples of all the items listed above. If we are aware of those -- so are the regulators. It will not be long before the trauma verification committee, JCAHO, CMS and others will began to check these on their visits to our institutions. We had  better be prepared and start to look for solutions of these oversights now. But more importantly, we MUST protect our patients and provide them with proper care not VOMIT.

Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of KMATTOX at aol.com
Sent: Wed 10/14/2009 7:34 PM
To: trauma-list at trauma.org
Subject: Excess Radiation from CT of concern at LA Hospital

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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Excess Radiation from CT of concern at LA Hospital