Abstract Given the rapid improvements in technology and machinery thatare used in health Centre’s across the globe, companies face huge pressures todevelop and engineer new and more innovative products, with the aim of aidinghospitals and professionals to be more efficient when examining and diagnosingpatients.
However, it should not come as a huge surprise for the technologybeing used to fail. In this article, I will be investigating the main causesthat lead to 206 patients at Cedar-Sinai health center being examined forpotential stroke, where new CT machines recently installed was used that leadto these patients being to a dangerous dose of radiation eight times theprescribed limit, also I will be outlining the measures which are now in placeto reduce such incidents happening in the future. Introduction Clinical medicine has without doubt been revolutionized with the aidof medical imaging. Modern-day imaging continues to provide detail and accuracybeyond believe, reflected in reduced hospital stays, more effective surgicaltreatments, improved treatment of cancer, elimination of exploratory surgeryand treatment of stroke patients just to list a few. Thefirst Computed tomography scanner developed by Godfrey Hounsfield backed by EMICentral Research Laboratories based in Hayes, West London, produced its firstimage on the 1st October 1971 at Atkinson Morley’s Hospital, locatedin London, England. The image produced was an 80 x 80 matrix, taking roughly 5minutes to generate by the prototype scanner, however in today’s technology, CTscanners are able to produce images with a 1024 x 1024 matrix from a fewmillion data points, in a few seconds, making it a crucial and valuable assetto the medical centers around the world. 1,5 A computedtomography fires narrow beams of x-rays at a patient, while rotating around thebody, this results in signals which can be detected by the x-ray detectorslocated directly opposite the x-ray beams and is processed by the computer togenerate a cross-sectional “slices ” of the body part, given the termtomographic images, these images contain a greater amount of detail than thatfound in x-ray images making them very useful tools to physicians, the slicesproduced are then “stacked” in the order produced by the machines computer toproduce a three dimensional image showing the inner structures as you would seeif you were to physically perform a surgical operation, so the doctors canidentify and locate any abnormalities or damage to the patient’s internalorgans.
Overtime CTscanners have become far more advanced the first clinical CT scanner wasdedicated to only producing head images only, as the effectiveness of thesemachines became more recognized around the world, in less than 6 years andthere are about 6000 Computed tomography scanners installed worldwide, and wereable to take whole body images. During its45-year history, Computed tomography functions at a far greater speed, andimprovement in resolution and patient comfort. As Computed tomography are ableto produce images faster, more anatomy can be scanned in far less time thanbefore this is important as it helps to eliminate any artefactsthat can arisefrom the patient motion. The CT machinesused to produce these images require the technicians to be fully trained inoperating them and understand the safe limits of radiation to which patientscan be exposed to, because of the dangerously high dosage of radiation thesemachines are capable and could be programmed to emit. But during aneighteen-month period at Cedars-Sinai Medical center, where 206 patients wereexposed to eight times the normal radiation dose, and 20% directly to theireye.
reports by IMV (Medical information division) in figure 2 shows therapid increase in the use of CT imaging in the United states, the radiationexposure associated with them over the last decade outline the dangers whichcould arise, clearly shown in the radiation overdose incident that took placeat Cedar-Sinai beginning February 2008 and after 18 months, for such a majorincident to occur indicates there are multiple causes which can be classifiedin two very different categories being the Medical Centre and the manufactures. Many sourcessuch as the ‘New York Times’ related the main cause to mainly human ‘error’,this came about as a result of thehospital started to use a new protocol for a specialized form of scan which was believed to provide doctors with more usefulinformation in their effort to treat stroke patients. So that meant resettingthe CT machines to be able to override the pre-programmed instructions whichaccompanied the scanner when it was first installed.Once these newinstructions were programmed into the machines, they were essentially lockedin. The machine was used for other types of scans which the ‘error’ did noteffect.
The 10’Swiss cheese’ model of organizational accidents, is anexcellent procedure which can be used to reduce the likelihood of accidentsoccurring in large organizations, the model is built on the idea of havingbarriers at each step in a process to eliminate any potential error before thefinal outcome, so in an event of a major error to occur all the holes will haveto line up this would be the case in a flawed system that would allow an erroror mistake at the beginning to reach and affect the outcome. So, to reduce thechances of an error effecting the outcome the more cheese slices used thesmaller the chances of errors and also the smaller the holes the better assmaller holes could imply a more detailed analysis at each stage of the processthat would ultimately catch or even stop the error becoming an accident.