Los Angeles medical radiography accident, 2008-2009 (original) (raw)

Database of radiological incidents and related events--Johnston's Archive

compiled by Wm. Robert Johnston
last modified 19 December 2009

**Date:February 2008-August 2009Location:Los Angeles, California, United StatesType of event:radiation overexposure during CT scansDescription:**Following implementation of a new procedure for CT imaging at Cedars-Sinai Medical Center, Los Angeles, stroke patients were overexposed during CT scans. From Feburary 2008 to August 2009, 206 patients received an estimated 300-400 rad exposures to the brain rather than the 50-100 rad intended. The error was discovered when a patient in August 2009 reported localized hair loss. After the incident case to the attention of the FDA in October 2009, similar accidental overdoses were reported from other sites: 14 cases at Glendale Adventist Medical Center, Los Angeles; an undetermined number of cases at St. Joseph's Medical Center in Burbank, California; and an unspecified number of cases at an unreported location in Alabama. Reportedly more than 250 patients were overexposed, with a limited number suffering skin redness and/or some hair loss.

**Consequences:**2+ injuries

References:

• FDA, 7 Dec. 2009, "CT brain perfusion scans safety investigation: Initial notification," FDA, on line [http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm186105.htm].
• FDA, 7 Dec. 2009, "FDA makes interim recommendations to address concern of excess radiation exposure during CT perfusion imaging," FDA, on line [http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm193190.htm].
• FDA, 8 Dec. 2009, "Safety investigation of CT brain perfusion scans: Update 12/8/2009," FDA, on line [http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm185898.htm].
• Phend, Crystal, 15 Oct. 2009, "CT safety warnings follow radiation overdose accident," MedPage Today, on line [http://www.medpagetoday.com/Radiology/DiagnosticRadiology/16455].
• Smith, Michael, 8 Dec. 2009, "FDA seeks to limit CT radiation exposure," MedPage Today, on line [http://www.medpagetoday.com/Radiology/DiagnosticRadiology/17381].

© 2009 by Wm. Robert Johnston.
Last modified 19 December 2009.
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