10.21.2009

Radiation Overdoses Highlight Process Flaws

A disturbing case of process failure is being reported out of Los Angeles, with word that CT scans with eight times the normal dose of radiation were given to 206 stroke patients at Cedars-Sinai Hospital over an 18-month period.

As reported in the Los Angeles Times, the overdoses should never have occurred because, with any given scan, the dose of radiation is displayed on a computer screen facing the technician.


The FDA and the state Department of Public Health are still investigating the overdoses. Cedars-Sinai has released only basic information, saying the overdoses stemmed from an error made when the hospital reconfigured a scanner to improve doctors' ability to see blood flow in the brain.
The CT machine in question performed several types of scans, each with its own set of computerized instructions, or protocols. To change the instructions for brain perfusion scans, the hospital had to bypass the protocol that came installed on the machine. Other types of scans were not affected.

In a statement issued Monday, hospital officials said they have "added double-checks to our process whenever a protocol is changed" -- raising questions about why such checks were not already in place.

Experts said it was just as worrisome that the hospital apparently missed opportunities to catch the mistake as possible stroke victims continued to be overdosed.

Asked how CT technicians could have missed the dosage levels on their screens, spokesman Richard Elbaum said that will be part of the hospital's investigation…

"There are other places where the techs might be operating more as button-pushers," said Dr. Geoffrey Rubin, a professor of radiology at Stanford University. "The user becomes a little blind to these numbers."


I haven’t seen any information yet as to what ill effects, if any, the patients may have suffered as a result of the radiation overdoses.

Clearly, the process needs to be addressed, with new safeguards built in – particularly when it comes to bypassing the scanner’s protocols. But I’m a little concerned about one comment in the Times article.


Najmedin Meshkati, a professor of industrial and systems engineering at USC, said the airline industry experienced a similar problem with the advent of automated cockpits. The operator must trust the machine, and "sometimes this trust may be misplaced," he said.

Meshkati said the overdoses point to a problem well-documented in medicine over the last decade -- the need for multiple backup systems to catch mistakes.


I’m not sure what he means by “backup systems.” It seems to me there may be a fairly simple solution. Recent news reports have described how some hospitals have reduced surgical errors through use of a surgical-room checklist, to make sure nothing is forgotten. (Can you say 'standard work'?)

How about a radiology checklist – including checking the radiation dose?

What are your suggestions?

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