Safety issues will likely take precedence over spectacle at this year?s RSNA.

Marianne Matthews
Marianne Matthews

RSNA 2009 is almost upon us. Like kids in a candy store, we?re all tempted to check out exciting innovations from a multitude of manufacturers. Booth visits remain an alluring highlight of the RSNA experience. But the medical imaging community was recently faced with some scary and sobering news. Matters of safety will likely reign over spectacle at this year?s RSNA meeting.

On October 13, Alan Zarembo reported the following in, ?Scores of radiation overdoses at Cedars-Sinai Medical Center have been traced to a single cause: a mistake the hospital made resetting a CT scanner.? The end result: 206 patients who received a CT brain perfusion scan during a specific 18-month period were subjected to a dose of radiation eight times higher than it should have been.

How did this accident happen?

The report states that the hospital began using a new protocol for the specialized type of scan to diagnose strokes in February 2008. It required resetting the CT machine to ?override the pre-programmed instructions that came with the scanner when it was installed.? According to officials at Cedars-Sinai, ?There was a misunderstanding about an embedded default setting applied by the machine ? As a result, the use of this protocol resulted in a higher than expected amount of radiation.?

The overdoses prompted the Food and Drug Administration (FDA) to issue a Safety Alert regarding CT brain perfusion scans for use in diagnosing stroke, urging hospitals to review their CT protocols and be aware of the dose indices normally displayed on the control panels.

But an even more shocking story concerning CT safety (or lack thereof) was recently reported in The New York Times (October 16, 2009). At Mad River Community Hospital in Arcata, Calif, a 2 1/2-year-old boy experiencing neck pain after falling off his bed was subjected to over an hour of CT scans. The procedure typically takes 2 or 3 minutes. As The Times reported, for reasons not yet fully understood, the x-ray technologist ?activated the CT scan 151 times on the same area, state investigators concluded.?

The test was terminated only after the child?s father had a hunch it was taking too long.

In The Times report, the attorney for the patient and his family noted that his radiation expert predicts that ?the child will develop cataracts in three to five years? and that the parents are subjected to far greater worry regarding additional consequences ?for the rest of their lives.?

What is the imaging community doing to ensure the safest use of imaging modalities? The people behind the Image Gently campaign, launched in 2008, should be commended for their responsible work. The campaign, which aims to lower radiation dose in pediatric patients, is spearheaded by the Alliance for Radiation Safety in Pediatric Imaging and is supported by GE Healthcare. ? Have you directed your staff and parents of pediatric patients to the Web site at Now would be a good time.

Moreover, you?ll find a plethora of educational events that cover safety issues?for both radiologists and radiological technologists?at this year?s RSNA. On the agenda is ?Why We Should Talk to Parents about Radiation Safety Issues,? led by Marilyn J. Goske, MD, and Dorothy I. Bulas, MD. In fact, there is an entire series for radiologic technologists called ?ASRT at RSNA,? which will cover key topics including radiation exposure and safety. ? Have you urged your techs to attend?

No one wants to miss out on the spectacle?the latest innovations are right there on the show floor for your review. But when manufacturers serve up the sizzle, ask about safety, too. The CEO of Mad River Community Hospital was paraphrased in The Times report, ?Manufacturers could help to prevent future errors by improving its internal settings and by installing more safeguards.? Let us know what new products you find that feature better safety standards. It?s a show of standards?a show of responsibility?that will make RSNA 2009 a show to remember.

Marianne Matthews