Hospital Error Leads to Radiation Overdosing
Tinkering with a complicated piece of machinery's default settings can be risky.
Consider the situation at Cedars Sinai Medical Center.
The plan was to improve stroke diagnoses, but adjustments to the CT scanner's settings resulted in more than 200 radiation overdoses. A hospital spokesman said about 40 percent of the patients lost patches of hair as a result.
Hospital officials said a computer resetting error caused radiation overdoses for 206 patients.
"There was a misunderstanding about an embedded default setting applied by the machine . . . ," hospital officials said in a written statement.. "As a result, the use of this protocol resulted in a higher than expected amount of radiation."
That higher-than-expected amount was eight times the normal dose. The error went undetected for 18 months until a stroke patient told officials that he was losing his hair after a scan, according to the LA Times.
After reviewing its records, hospital officials contacted the patients and informed them of the mistake.
The idea was to employ a new protocol for a CT brain perfusion scan. The scan is designed to help diagnose strokes. By overriding the machine's pre-programmed instructions, doctors thought it would provide information about blood flow to the brain.
Although the scanner was used for other types of scans, only potential stroke patients were affected, according to Richard Elbaum, a hospital spokesman.
The scanners' manufacturer is General Electric, the parent company of NBC Universal. GE says the machine was not defective.
As a result of the discovery, the FDA issued an alert last week urging hospitals nationwide to review their safety protocols for CT scans.
