Overview
- Exposure spanned 2012 to 2024 and affected 451 children, with some doses reported as up to four times reference values while the hospital says exposures stayed below 100 millisieverts.
- The incident came to light on December 2, 2024, when a radiologist flagged an abnormally high dose for an 8-year-old, prompting a formal alert to regulators on December 20.
- Investigators found an Apelem Platinum table had been set to continuous fluoroscopy instead of pulsed mode since installation in 2012, significantly increasing patient dose.
- ASNR also cited partial dose reporting, a dose-archiving system that did not ensure compliant documentation, and gaps in staff training and authorization for certain procedures.
- The hospital has corrected settings, retrained teams, and added automatic dose tracking in reports, and ASNR plans a nationwide inspection campaign of radiology services starting in 2026.