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Cedars-Sinai says error led to radiation overdoses on stroke patients [Updated]

October 12, 2009 |  8:08 pm

A hospital computer-resetting error led to radiation overdoses of 206 patients who underwent CT scans at Cedars-Sinai Medical Center in the last 18 months, hospital officials said Monday in a statement.

[Updated at 9 p.m.: A previous version of this post stated that the overdoses were caused by a computer-programming error. They were in fact the result of an error the hospital made in resetting the machine, hospital officials said Monday night.]

In February 2008, the hospital began using a new protocol for CT brain perfusion, a procedure used to diagnose strokes. That meant overriding the instructions that came pre-programmed in the machine to provide doctors with better information.

“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.”

General Electric, the manufacturer of the scanner, released its own statement Monday saying that there were “no malfunctions of defects” of the machine.

About 40% of the patients lost patches of hair as a result of the overdoses, a hospital spokesman said.

Even so, the overdoses went undetected for 18 months as patients received eight times the dose normally delivered in the procedure, raising questions about why it took Cedars-Sinai so long to notice that something was wrong.

As a result of the discovery, the FDA issued an alert Thursday urging hospitals nationwide to review their safety protocols for CT scans.

-- Alan Zarembo

Related Items:

Read more Times coverage of this story 

Contact the reporter with your personal experiences related to this story

FDA's notice: Safety Investigation of CT Brain Perfusion Scans: Initial Notification

Read Cedars-Sinai's official statement on radiation overdoses

Photo: Associated Press

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