Oops is now a medical term in Brooklyn

Walt Bogdanich and Kristina Rebelo have an article in The New York Times about a medical screwup in Brooklyn that sounds to Rico like a lawsuit in the making:

Long after a major Brooklyn hospital said it had stopped over-radiating premature babies, state inspectors have found that some inappropriate X-rays were still being administered as recently as January, state records show.
Claudia Hutton, a spokeswoman for the New York State Department of Health, said state regulators suspected that similar cases were occurring at other hospitals. The department is deciding whether to conduct spot checks around the state to determine the extent of the problem.
The inspection at the Brooklyn hospital, the State University of New York Downstate Medical Center, in March, was prompted by an article in The New York Times in February, revealing that, in 2007, the hospital had discovered that premature babies— the most vulnerable of all patients— were frequently subjected to whole-body X-rays when only chest exams had been ordered. These errors had never been reported to state health officials.
Downstate officials said they had promptly put an end to the risky X-ray practices. But, last month, state inspectors reviewed chest X-rays of premature babies taken late last year and early this year and found 27 instances of infants’ irradiated beyond the chest area without proper shielding. Some premature infants were over-radiated multiple times, inspection records show.
“We were disappointed to find so many X-rays in our sampling that did not have adequate shielding to protect infants from being exposed to excess radiation,” said Dr. Nirav R. Shah, the state health commissioner. “Additional training and monitoring must be put into place to rectify this situation.”
In a brief statement released by Ronald Najman, a Downstate spokesman, the hospital said that, in the wake of the inspection, it had addressed the issues raised by regulators “to ensure that we provide quality care to our patients.” The statement did not say why the problems had continued after radiologists at the hospital said they had stopped the original improper scanning practices.
Children are particularly vulnerable to radiation’s effects because their cells divide quickly and because they face an ever-increasing number of radiological procedures over their lifetime as new medical uses are found for radiation. X-rays are invaluable in diagnosing internal complications. But minimizing exposure is important because most scientists believe the effects of radiation are cumulative, meaning the more radiation one receives, the greater the chances of developing cancer later in life.
The state inspection on 9 March found “neonatal imaging was not provided in accordance with physician orders and the facility policies and procedures,” according to a statement of deficiencies sent to the hospital on 21 March.
The first case cited in the report involved a baby born prematurely, at 26 weeks, who received five chest X-rays over a period of two months in which the radiation was not properly limited, or coned, to the chest area. For example, one “showed the patient’s neck, chest, abdomen, the upper arms, and a small section of the right thigh.”
A second baby who was to have a chest X-ray had an image taken that included “the entire head, left arm, right arm, chest, and abdomen,” the report said.
According to the state, one radiologist explained the wide areas of irradiation by saying that “technologists were sometimes instructed at the bedside by physicians to include additional areas of interest in the chest X-ray.” Ms. Hutton, the state health department spokeswoman, said that explanation was unacceptable when the official medical record called only for a chest X-ray. “You shouldn’t be taking X-ray views not ordered by the doctor,” she said, “and if the doctor ordered them, they should be in the chart.”
According to the inspection report, the 27 improper X-rays were found among 542 chest images reviewed by state inspectors.
Ms. Hutton said if a fine was imposed, it would probably be a small one. “We just want compliance,” she said. “This is not a revenue stream for us.”
The hospital’s failure to report the problems in 2007 rankled state regulators. “You could have called us and said, ‘We just found something really bad,’ ” Ms. Hutton said. “We had to learn about the issue from The New York Times.”
The Times article quoted extensively from internal emails at Downstate, including one from 2007, in which Dr. Salvatore J. A. Sclafani, the radiology chairman, wrote that he was “mortified” to find that the same premature infant had received about ten whole-body X-rays when only a simple chest X-ray had been ordered. “Full, unabashed, total irradiation of a neonate,” Dr. Sclafani said, adding, “This poor, defenseless baby.” Dr. Sclafani recently took a leave from his position to do research.
Downstate officials told The Times during the winter that, back in 2007, the hospital had instituted procedures intended to minimize exposure to radiation. The steps included reducing the radiation dose administered to pediatric patients undergoing CT scans, and eliminating CT scans that were not absolutely necessary. According to doctors familiar with Downstate procedures, those steps did reduce exposure to radiation from CT scans.

Rico says if 'training and monitoring' aren't enough, how about a whopping lawsuit by the affected families? That oughta cure it...