Abstract Given the rapid improvements in technology and machinery that
are used in health Centre’s across the globe, companies face huge pressures to
develop and engineer new and more innovative products, with the aim of aiding
hospitals and professionals to be more efficient when examining and diagnosing
patients. However, it should not come as a huge surprise for the technology
being used to fail. In this article, I will be investigating the main causes
that lead to 206 patients at Cedar-Sinai health center being examined for
potential stroke, where new CT machines recently installed was used that lead
to these patients being to a dangerous dose of radiation eight times the
prescribed limit, also I will be outlining the measures which are now in place
to reduce such incidents happening in the future.



Introduction Clinical medicine has without doubt been revolutionized with the aid
of medical imaging. Modern-day imaging continues to provide detail and accuracy
beyond believe, reflected in reduced hospital stays, more effective surgical
treatments, improved treatment of cancer, elimination of exploratory surgery
and treatment of stroke patients just to list a few.


first Computed tomography scanner developed by Godfrey Hounsfield backed by EMI
Central Research Laboratories based in Hayes, West London, produced its first
image on the 1st October 1971 at Atkinson Morley’s Hospital, located
in London, England. The image produced was an 80 x 80 matrix, taking roughly 5
minutes to generate by the prototype scanner, however in today’s technology, CT
scanners are able to produce images with a 1024 x 1024 matrix from a few
million data points, in a few seconds, making it a crucial and valuable asset
to the medical centers around the world.


1,5 A computed
tomography fires narrow beams of x-rays at a patient, while rotating around the
body, this results in signals which can be detected by the x-ray detectors
located directly opposite the x-ray beams and is processed by the computer to
generate a cross-sectional “slices ” of the body part, given the term
tomographic images, these images contain a greater amount of detail than that
found in x-ray images making them very useful tools to physicians, the slices
produced are then “stacked” in the order produced by the machines computer to
produce a three dimensional image showing the inner structures as you would see
if you were to physically perform a surgical operation, so the doctors can
identify and locate any abnormalities or damage to the patient’s internal

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Overtime CT
scanners have become far more advanced the first clinical CT scanner was
dedicated to only producing head images only, as the effectiveness of these
machines became more recognized around the world, in less than 6 years and
there are about 6000 Computed tomography scanners installed worldwide, and were
able to take whole body images.


During its
45-year history, Computed tomography functions at a far greater speed, and
improvement in resolution and patient comfort. As Computed tomography are able
to produce images faster, more anatomy can be scanned in far less time than
before this is important as it helps to eliminate any artefacts

that can arise
from the patient motion.


The CT machines
used to produce these images require the technicians to be fully trained in
operating them and understand the safe limits of radiation to which patients
can be exposed to, because of the dangerously high dosage of radiation these
machines are capable and could be programmed to emit. But during an
eighteen-month period at Cedars-Sinai Medical center, where 206 patients were
exposed to eight times the normal radiation dose, and 20% directly to their



reports by IMV (Medical information division) in figure 2 shows the
rapid increase in the use of CT imaging in the United states, the radiation
exposure associated with them over the last decade outline the dangers which
could arise, clearly shown in the radiation overdose incident that took place
at Cedar-Sinai beginning February 2008 and after 18 months, for such a major
incident to occur indicates there are multiple causes which can be classified
in two very different categories being the Medical Centre and the manufactures.


Many sources
such as the ‘New York Times’ related the main cause to mainly human ‘error’,
this came about as a result of the
hospital started to use a new protocol for a specialized form of scan which was believed to provide doctors with more useful
information in their effort to treat stroke patients. So that meant resetting
the CT machines to be able to override the pre-programmed instructions which
accompanied the scanner when it was first installed.

Once these new
instructions were programmed into the machines, they were essentially locked
in. The machine was used for other types of scans which the ‘error’ did not


The 10’Swiss cheese’ model of organizational accidents, is an
excellent procedure which can be used to reduce the likelihood of accidents
occurring in large organizations, the model is built on the idea of having
barriers at each step in a process to eliminate any potential error before the
final outcome, so in an event of a major error to occur all the holes will have
to line up this would be the case in a flawed system that would allow an error
or mistake at the beginning to reach and affect the outcome. So, to reduce the
chances of an error effecting the outcome the more cheese slices used the
smaller the chances of errors and also the smaller the holes the better as
smaller holes could imply a more detailed analysis at each stage of the process
that would ultimately catch or even stop the error becoming an accident.


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