CT Radiation Overdoses Caused by User Error, FDA Says

HealthLeaders Media Staff, November 16, 2010

User error, not technological problems, is to blame for cases of excess radiation in computed tomography scans, the U.S. Food and Drug Administration says.

The FDA has been investigating reports that patients undergoing CT brain perfusion scans were accidently exposed to excess radiation. The FDA announced this week it found that when properly used, the CT scanners did not malfunction. Rather, it's likely improper use of the scanners resulted in the overdoses.

Nevertheless, the FDA identified a series of steps intended to enhance the safety of these procedures. The steps could reduce the likelihood of radiation overexposure in the event of CT scanners' improper use.

Back in October 2009, the FDA encouraged CT facilities to review their protocols and make sure that the values displayed on the control panel corresponded to the doses normally associated with the protocol. Based on its investigation to date, the FDA made additional recommendations to facilities. Among them:

  • Assess whether patients received excess radiation during CT perfusion scans.
  • Review radiation dosing protocols for all CT perfusion scans to ensure the correct dose is planned for each study.
  • Implement quality control procedures to ensure dosing protocols are followed every time, and that the planned amount of radiation is administered.
  • Check the display panel before performing each scan to make sure the amount of radiation to be delivered is appropriate for the individual patient.
  • Be certain, and document, that radiologic technologists are trained on the specific scanner and for the specific imaging protocol they are using.
  • CT operators should be specifically trained on dose-saving features, such as automatic exposure control, before using them.
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