Calif. hospital fined for X-ray overdose of a child

The overdosing underscores the call by radiology associations for greater safety for pediatric patients.

The California Department of Public Health has fined a northern California hospital $25,000 for giving an excessive radiation dose to a 2-year-old boy last year.

Carrie and Padre Roth filed a complaint against Mad River Community Hospital in Arcata after their son, Jacoby, underwent a computed tomography (CT) exam in the ER for a possible neck injury on January 23, 2008. They charged that Jacoby received radiation burns and permanent chromosomal damage from excessive radiation exposure after a CT technologist took repeated scans -- 151 scans in all -- of the boy’s face and neck area.

According to the state investigators’ report released earlier this month, the hospital failed to follow its own policies and procedures regarding radiation safety. Investigators also found that the hospital was not compliant with state licensing requirements.

The boy received an estimated radiation dose of 2.8 to as high as 11 Gy, according to a report submitted by the hospital’s medical physicist. The physicist wrote that the overexposure increased the child’s lifetime risk of developing a fatal cancer by 39 percent.

In her testimony, the radiologic technologist stated that she believed the machine was broken and she repeated the scan numerous times so they would register a complete image. A supervisor in charge denies the technologist's claim that she called for help and that the machine was broken.

The technologist responsible for the CT overdose was let go. She has appealed the suspension of her license to practice in California, according to a local newspaper, the Times-Standard.

Mad River Community Hospital contends that it did not violate its state license and it objects to the health department’s “manner of investigation and decision-making process.” CEO Doug Shaw has issued a statement saying the hospital intends to appeal the $25,000 fine.

Radiation experts say Image Gently

logo of the Alliance for Radiation Safety in Pediatric Imaging

While this case is one of employee incompetence and lax hospital safety policies, it draws attention to the risks associated with the growing use of ionizing radiation in diagnostic testing, particularly among pediatric patients.

A consortium of 13 medical radiology societies has formed the Alliance for Radiation Safety in Pediatric Imaging and an “Image Gently” initiative to encourage physicians and hospitals worldwide to adopt safer protocols for pediatric radiation, and to always consider whether the medical diagnosis can be met through alternative imaging methods such as ultrasound or magnetic resonance imaging (MRI) which do not involve ionizing radiation. 

The alliance says that about 7 million CT studies are performed on children annually, with the number of pediatric CTs growing 10 percent each year. 

The radiation levels equal to CT scans do cause cancers in some people, according to the alliance. It states that children are more at risk of developing cancers later in life from CTs because they have more radiosensitive tissues, they often receive a larger effective dose for a given level of radiation, they have a longer time to develop cancers resulting from radiation exposure, and the risks from CTs are cumulative. Each subsequent scan increases the risks.

The Image Gently Alliance has also prepared educational materials to help parents understand the risks of CTs and suggests keeping records of their children’s CT scan history.

The American Academy of Pediatrics, an alliance member, advises: “The medical community should seek ways to decrease radiation exposure by using radiation doses as low as reasonably achievable and by performing these studies only when necessary.” (Report pdf)