Today, it was reported that one of the high quality hospital in California has been using CT scanner setting that exposed patient to radiation level higher by 8-10 times the normal dose.  It is even more ironical that the mistake was not discovered till the patients started showing symptoms of hair loss and others.

The treatment exposed over 200 people to this dangerous level of radiation.  And this practice continued unnoticed for over a year.  In an ABC report, it was pointed that these people have 1 in 100 chance of getting cancer due to the overdose.

GE, the manufacturer came out quickly with the statement that there is nothing wrong with the machine. And hospital does agree that it was error.  In the light of all this, and our ongoing discussion about inordinate amount of avoidable deaths and injuries in the hospital, and the fact that these have not changed in decades, one must ask the following questions.

• Why a generally higher paid medical staff is not able to do the right thing?
• What is the reason that the efforts of years have not made any dent in the avoidable injuries and deaths in the hospitals?
• Who is responsible for higher malpractice premiums?  the lawyers or the lack of proper process and management!
• Why does the CT scanner have the ability to generate 10 fold higher radiation?  I am not sure of it, but is there a medical need for that intensity?
• While it is important that the hospital should have had a procedure to catch the mistake; why did GE if knew these mistakes can happen, created a way to know and indicate the higer levels of radiation.  Some sort of alarm!
• Hospitals have been working hard to eliminate errors.  Then how come still they have such blunders going uncaptured?

These questions and many more lead to some simple things.  There is a saying that it is insane to expect new result by doing the same thing.  So what we have to ask is if there is going to be a continuation of same thing or people are going to wise up and try new ideas.

I have seen so many people doing risk analysis and mitigation plans.  It is sad that they are able to come across as the expert.  But when you really audit their work, you can undestand why the risks are rarely mitigated.

I call upon all the hospitals to spend time in creating clinical, diagnostics, testing etc. processes that are based on in depth root cause analysis and risk assessments.

I do not believe they need to put any more money for it.  It is about utilizing the finances they already spend and create a controlled process and procedure that saves them money.

It is possible and simple if the right resources are put to task.