Database of radiological incidents and related events--Johnston's Archive
Arcata medical radiography accident, 2008
compiled by Wm. Robert Johnston
last modified 19 December 2009
23 January 2008
Mad River Community Hospital, Arcata, California, United States
Type of event:
radiation overexposure during CT scan
A 23-month old boy received a radiation overexposed during multiple CT scans at Mad River Community Hospital. The boy was brought to the hospital ER for a possible neck injury. The CT technologist made a total of 151 CT scans of the boy's face and neck area over a period of 65 minutes, until the boy's father objected to the process. The technologist stated she thought the machine was broken and pushed the scan button four times in order to register a complete image. A second technologist made 25 successful CT scan images about 90 minutes later in a one minute period. The second technician was "horrified" when she saw the records of the earlier scans and reported the imaging department manager. The boy developed radiation burns on the cheeks and around the head and neck in a plane from under the eyes through the ears and neck. A subsequent investigation concluded that the first technician had to have pushed the scan button 151 times, and estimated the boy received a localized dose of 280 rad or up to 1100 rad "using a factor of four for pediatric size and makeup," also estimating an additional lifetime risk of fatal cancer of 39%.
- Anonymous, 22 Sept. 2009, "CT overdose hearing in California," The Sharp End of the Photon, on line, [http://www.drflounder.com/archives/533].
- California Health and Human Services Agency, 22 Jan. 2009, "2567 Mad River Community Hospital," California Health and Human Services Agency, on line [http://www.cdph.ca.gov/certlic/facilities/Documents/HospitalAdministrativePenalties-2567Forms-LNC/2567MadRiverCommunityHospital-Humboldt-Event-DUB511.pdf].
- Ferris, John, 2009, "Computed tomography (CT) proposed rules for radiation safety," Michigan.gov, on line [http://www.michigan.gov/documents/mdch/bhs_20091027_con_seminar_299155_7.ppt].
- Stone, Kathlyn, 26 March 2009, "Calif. hospital fined for X-ray overdose of a child," Flesh and Stone, on line [http://www.fleshandstone.net/policy_trends/radiationoverdose.html].
- Tam, Donna, 5 March 2009, "Mad River Community Hospital set to challenge state penalty," Times-Standard, on line [http://www.times-standard.com/localnews/ci_11841717].
© 2009 by Wm. Robert Johnston.
Last modified 19 December 2009.
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