Doctors have expressed outrage and concern for the unsuspecting patients who received eight times the normal dose of radiation during a specific type of brain scan at Cedars-Sinai Medical Center in Los Angeles.
The overdose was discovered when a patient reported lost patches of hair following a CT scan.
The error, which Cedars-Sinai attributed to a "misunderstanding" about an incorrectly programmed CT machine, in a statement released Oct. 12, remained unchecked for 18 months, involved 206 people, and exacerbated existing concerns that patients nationwide are being exposed to excess radiation during medical testing.
"To me, even as a professional, this is a fairly shocking story. These patients received 8-10 times the normal dose for a head CT and probably reached their allowable radiation exposure for the year at a single test," said Dr. James Slater, associate professor of cardiology at the NYU Langone Medical Center. "The fact this error occurred and went undetected for 18 months at a well regarded medical [institution] is rather unbelievable."
Diagnostic imaging tests have increased Americans' average radiation exposure seven times since 1980, according to the National Council on Radiation Protection and Measurements, and increased exposure leads to increased cancer risk.
While occupational radiation exposure is regulated by the government, there is no federal oversight when radiation is used for medical purposes.
"There is no government limit on what you can give a patient when it's a diagnostic test," said Dr. Gary Freedman, a radiation oncologist at Fox Chase Cancer Center in Philadelphia. "It's assumed that medically, you do what you need to do and worry about the complications later."
But the radiation doses that the Cedars-Sinai patients received were significantly higher than intended. In some cases, these patients, who were undergoing CT brain perfusion scans, often used to monitor stroke patients, received twice as much radiation as the average cancer patient would receive in one treatment.
That much radiation in a single dose can be enough to cause temporary hair loss, and is certainly high enough to cause skin redness and irritation, Freedman said. Cedars-Sinai reported that 40 percent of the affected patients experienced redness and hair loss.
Still, doctors said the chance that a one-shot exposure to excess radiation would increase the risk of developing cancer or have other significant long-term health effects in these patients -- whose average age was 70 -- was small.
"Fortunately in this case, there appears to be no evidence that patients have suffered any life-threatening or irreversible injury [including] neurologic injury," said Dr. Leonard Berlin, professor of radiology at Rush University Medical College. "Reactions to the radiation exposure are regrettable and uncomfortable, but fortunately, will spontaneously disappear without any residual effect."
The most pressing issue, after seeing whether patients were permanently harmed, is that the error went uncorrected for over a year.
"The risk of further tumors is really small," Freedman said. "But this was an error and it's not OK that [patients] got eight times what they should have...