An investigation has been launched into botched CT brain scans that were performed at Cedars-Sinai Medical Center in Los Angeles, California. On Friday, the Food and Drug Administration (FDA) issued an alert to hospitals nationwide, warning them to review their safety procedures for CT scans. However, the alert did not name Cedars-Sinai specifically.
According to the Associated Press, officials at Cedars-Sinai said on Friday that 206 patients got eight times the regular dose of radiation during CT brain scans, which are used to diagnose strokes. According to the FDA alert, patients involved in these incidents had received radiation doses of 3-4 Gy to the head, rather than the expected dose of 0.5 Gy (maximum).
The machine at Cedars-Sinai had been set at the higher level since February 2008, the Associated Press said, but the mistake had not been detected for 18 months. According to the Medical Center, the overdoses were discovered in August, when a patient reported hair loss. Other patients had also suffered hair loss and skin reddening. Cedars-Sinai has notified all patients who received the overexposure and provided resources for additional information.
In its alert, the FDA said it was concerned that the radiation overdosing “may reflect more widespread problems with CT quality assurance programs and may not be isolated to this particular facility or this imaging procedure (CT brain perfusion). If patient doses are higher than the expected level, but not high enough to produce obvious signs of radiation injury, the problem may go undetected and unreported, putting patients at increased risk for long-term radiation effects.”
The FDA is encouraging every facility performing CT imaging to review its CT protocols and be aware of the dose indices normally displayed on the control panel. An FDA spokesperson told the LA Times that it does not yet know what led to the overdoses at Cedars-Sinai. They may have been the result a device malfunction, or appropriate procedures may not have been followed.
According to the LA Times, a statement issued by Cedars-Sinai said that since the overdosing was discovered, it had “instituted additional double-checks in its operations of the scanner and additional equipment protocols to ensure that this does not happen again.”
In addition to the FDA, the overdoses at Cedars-Sinai are being investigated by the California Department of Public Health. Depending on the outcome of the state investigation, the hospital could face restrictions on doing CT scans under its state license, LA Times said.
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October 13th, 2009 at 5:49 am
How could something have been this seriously wrong for so long? If their normal checks didn’t notice this at all, double-checks aren’t going to make any difference.
Tell you what, I normally frown at the whole idea of lawsuits, but in this case, this place deserves whatever legal hell it enters – this is shocking.
October 13th, 2009 at 1:01 pm
Wow! Think back to the 2 x over doses at a Florida cancer center in April 05.
Always question the dosage.
October 14th, 2009 at 6:49 am
I doubt this was an equipment failure. If it were, these computers hold imformation for months about errors. I suspect this occurred because of the protocol that was followed to achieve the images. These protocols are suggested by the equipment manufacturer, but can be overwritten by the overseeing Radiologist, Neurologist or technologist. This incident reinforces the idea of being an active participant your health care and asking questions of everyone you encounter.
October 14th, 2009 at 6:41 pm
I have worked in healthcare for 35 years. Cedars overdosed me on chemo and almost killed me. I have even worked in their mgt. depts. years ago. I would not let a dog be treated at Cedars. While there are in fact some capable physicians the overall work product from the bottom to the top is beyond sub standard.
I recently had a disc fusion, the sheets and blankets where thread bare and ink stained. And I had to explain to an RN to get an elbow board for my arm to stop the IV from beeping. Nice, I am problem solving for a registered nurse.
October 15th, 2009 at 3:11 pm
I was at Cedar Sinai from January through April 2008 for a brain hemorrhage and received several CT Scans while there. I was never contacted by the hospital and only discovered the problem when reading a NY times article. I have contacted my family physician to determine if I could have had exposure to the overdose. If anyone has information which might be helpful in determining whether I could have been exposed, I would greatly appreciate it. I assume you’d have to contact this web site for my email address.
October 17th, 2009 at 11:06 am
Is there only one CT machine at Cedars or multiple ones? Where on the hospital campus is this machine (or machines) located?
October 28th, 2009 at 10:33 am
I received a CT Scan on Dec. 29, 2008 at a hospital in Schenectady, NY. In July I noticed a dime sized spot of alopecia which since then has grown to a three inch in diameter circle. I saw a dermatologist in July who asked what trauma I may have suffered six months prior to the appearance of the alopecia. I’m wondering if I should contact the hospital and have them look into this.
October 31st, 2009 at 7:33 am
My father went for for cat scans and mris three or four times in one month and has been experiencing burning sensation and red inflamation on his skin and fatigue along with headaches and is worried that it maybe radiation poisoning is that possible that he may have it and are those some of th esymptoms that i mentioned?