Accidents

Cedars Sinai Medical Centre Scanner

A software misconfiguration led to 206 patients receiving radiation doses approximately 8 times higher than intended; the error persisted for 18 months.

A software misconfiguration in a Computed Tomography (CT) scanner used for brain perfusion scanning  at Cedar Sinai Medical Center in Los Angeles, California, resulted in 206 patients receiving radiation doses  approximately 8 times higher than intended. This error persisted for an 18 month period, starting in  February 2008. Some patients reported temporary hair loss and erythema.

The problem reportedly arose from an error made by the hospital in resetting the CT machine after it  began using a new protocol for the procedure in February 2008. The error was not detected until one of  the patients reported patchy hair loss in August 2009. “There was a misunderstanding about an embedded  default setting applied by the machine,” according to a statement from Cedars-Sinai. “As a result, the use  of this protocol resulted in a higher than expected amount of radiation.”

This incident highlights the importance of the verifiability Data Property, especially with regards to default  (and adaptation) data.

Links 

• http://articles.latimes.com/2009/oct/10/local/me-cedars-sinai10
  (accessed 29 November 2017).