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CT Brain Scans At Cedars-Sinai investigated – Dosage Settings Too High

Posted Oct 10 2009 10:01pm

Cedars found the overdoses back in August and began their own investigation after patients were complaining of hair loss and red irritated skin.  As a result the FDA has sent out a warning letter advising for safe settings for scanners.   8 times the normal dose is pretty big and I guess in 18 months image nobody had in fact checked the settings for any reason? 

The FDA is now recommending that after the scan the setting be checked to ensure the right dose has been given.   This could also be helped along with software configurations before scan begin too with a screen that requires the tech to verify the settings before a scan could take place. 

Change the parameters of the algorithms used before the procedure, hard code and compile so it is permanently part of each procedure done is what I would think would solve some of this and of course there’s a reissue or upgrade of the software.  BD

More than 200 patients at Cedars-Sinai Medical Center were inappropriately exposed to high doses of radiation during CT brain scans used to diagnose strokes, hospital officials told The Times today. 

For 18 months, the problem went undetected as patients received eight times the dose normally delivered using a CT brain perfusion scan.

“The magnitude of these overdoses and their impact on the affected patients were significant,” according to an FDA alert sent nationwide to hospitals Thursday. FDA officials, who did not name the hospital involved, told all facilities to review their safety procedures for CT scans and warned that undetected overdoses put "patients at increased risk for long-term radiation effects."

A spokesman for the California Department of Health said today that the department is investigating the overdoses at Cedars-Sinai.

Cedars-Sinai investigated for significant radiation overdoses of 206 patients | L.A. NOW | Los Angeles Times

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