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Cedars-Sinai Medical Center recently made a startling discovery: because of a setting error, hospital staff realized that at least 200 potential stroke patients were given CT scans at radiation doses 8 times the normal level.

On Monday, doctors admitted that the error occurred in February 2008, the same time that the hospital started a new protocol for scanning for potential strokes in patients. Specifically, doctors thought that the new procedures would help them to gather more useful data in analyzing the flow of blood to brain tissue.

Apparently, when a hospital employee set the scanner, they did not fully understand the set of directions that came with the machinery. Instead, they set the scanner at 8 times the normal radiation levels, which remained the default setting for the next 18 months. Doctors weren’t aware of the problem until a patient contacted the hospital to report that his hair had started falling out after receiving a CT scan. In response, hospital staff reviewed their records and found that 206 patients had received the higher dosages of radiation from the CT machine. When contacted, most of those patients also reported patchy hair loss as well as reddening of their skin. Fortunately, the incident prompted the Food and Drug Administration to issue a warning to all hospitals to check their CT scanners to make sure they are properly set.

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