BILL ANALYSIS                                                                                                                                                                                                    �






                                 SENATE HEALTH
                               COMMITTEE ANALYSIS
                       Senator Ed Hernandez, O.D., Chair


          BILL NO:       SB 38                                       
          S
          AUTHOR:        Padilla                                     
          B
          AMENDED:       As Introduced                               
          HEARING DATE:  March 23, 2011                              
          3
          CONSULTANT:                                                
          8              
          Trueworthy                                                 
                                     SUBJECT
                                         
            Radiation control: health facilities and clinics records

                                     SUMMARY
                                         
          Technical clean-up to clarify the effective dates 
          hospitals, imaging centers and the California Department of 
          Public Health (DPH) must comply with reporting requirements 
          for inappropriate or excessive radiation occurring during 
          computed tomography (CT) examinations or radiation therapy. 
           SB 38 clarifies the reporting date to be effective on July 
          1, 2012 rather than January 1, 2011.

                             CHANGES TO EXISTING LAW  

          Existing law:
           Establishes the Radiologic Health Branch (RHB) within 
            DPH, which is responsible for the licensing of 
            radioactive materials, registration of X-ray producing 
            machines, certification of X-ray and radioactive material 
            users, inspection of facilities using radiation, 
            investigation of radiation incidents, and surveillance of 
            radioactive contamination in the environment.

           Requires DPH to license persons who receive, possess, or 
            transfer radioactive materials, and devices or equipment 
            utilizing these materials.

           Requires a health facility to report to DPH effective 
            January 1, 2011, except as specified, an event in which 
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            the administration of radiation results in any of the 
            following:
               --Repeating of a CT examination, unless otherwise 
               ordered by a physician or radiologist, if specified 
               dose values are exceeded;

               --CT X-ray irradiation of a body part other than that 
               intended by the ordering physician or a radiologist, 
               if specified dose values are exceeded;

               --CT or therapeutic exposure that results in 
               unanticipated permanent functional damage to an organ 
               or a physiological system, hair loss, or erythema, as 
               determined by a qualified physician;

               --A CT or therapeutic dose to an embryo or fetus that 
               is greater than 50 mSv (5 rem) dose equivalent, that 
               is a result of radiation to a known pregnant 
               individual, unless the dose to the embryo or fetus was 
               specifically approved, in advance, by a qualified 
               physician;

               --Therapeutic ionizing irradiation of the wrong 
               individual, or wrong treatment site; and,

               --The total dose from therapeutic ionizing radiation 
               delivered differs from the prescribed dose by 20 
               percent or more, except in any instance where the 
               radiation was utilized for palliative care; however, 
               the radiation oncologist would be required to notify 
               the referring physician that the dose was exceeded.

           Requires the facility, no later than five business days 
            after discovery of an event, to notify DPH and the 
            referring physician of the person who is the subject to 
            the event, and, no later than 15 business days after 
            discovery of an event, to provide written notification to 
            the person who is the subject of the event.

          This bill:
           Requires facilities to report events for inappropriate or 
            excessive radiation occurring during CT examinations or 
            radiation therapy, as defined, beginning July 1, 2012, 
            rather than January 1, 2011.





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                                  FISCAL IMPACT
                                         
          This bill has not been analyzed by a fiscal committee.  
          However, according to the Assembly Appropriations Committee 
          analysis of SB 1237 in 2010, which requires hospitals and 
          imaging centers to report to DPH an event in which the 
          administration of radiation results in an overdose, the 
          reporting requirements resulted in no direct fiscal impact 
          to DPH.

                            BACKGROUND AND DISCUSSION  

          The author and supporters state this bill is a technical 
          clean-up measure to SB 1237 (Padilla) 2010, Chapter 52l to 
          clarify the effective date for reporting requirements for 
          inappropriate or excessive radiation occurring during CT 
          examinations or radiation therapy is July 1, 2012, as 
          opposed to January 1, 2011.

          The author and sponsor state that Californians are at 
          increasing risk of over radiation, and cites statistics 
          that total exposure to ionizing radiation has nearly 
          doubled over the past two decades, in large part because of 
          increased use of CT scans for medical diagnostic and 
          treatment purposes.  The author and sponsor state that 
          medical radiation can save lives, but can be deadly if 
          improperly administered, and can increase a person's 
          lifetime risk of developing cancer.  The author and sponsor 
          cite problems at Cedars-Sinai Medical Center in 2009, in 
          which 206 patients were exposed to overdoses of radiation 
          over an 18-month period, roughly eight times the 
          recommended level of radiation, when a scanner used for 
          brain scans was reconfigured.  The author and sponsor argue 
          that over radiation is difficult to detect if there is no 
          record of the dosage administered, which SB 1237 of 2010 
          will ensure.

          SB 1237 (Padilla, Chapter 521, Statutes of 2010) added 3 
          new sections to the Health and Safety Code relating to CT 
          X-rays.  Section 1 required, as of July 1, 2012, that 
          facilities using CT for diagnostic purposes, record the 
          dose of radiation used during the administration of the 
          radiation in the patient's medical record.  Section 2 
          required, as of July 1, 2013, facilities that furnish CT 
          X-ray services to be accredited by an organization that is 




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          approved by the Centers for Medicare and Medicaid Services, 
          the Medical Board of California, or DPH.  Section 3 stated 
          that a facility is required to report to DPH an event in 
          which the misadministration of radiation occurs on a 
          patient.  Section 3 did not include a delayed 
          implementation date and, therefore, became effective 
          January, 1, 2011.   

          On August 30, 2010, Senator Padilla submitted a letter to 
          the Senate Daily Journal that stated his intent to 
          implement the effective date of Section 3 of SB 1237 as 
          July 1, 2012.  This bill is intended to correct this error 
          by changing the effective date.  Extending the date allows 
          facilities the time needed to implement internal procedures 
          needed for reporting inappropriate or excessive radiation 
          that occurred during CT examinations or radiation therapy 
          procedures to DPH.  

          DPH has posted on its website and disseminated to the 
          industry a Frequently-Asked-Questions (FAQ) document that 
          informs facilities how to report and what information 
          should be reported.  The following information must be 
          provided to the RHB of DPH in a timely fashion when 
          reporting events for inappropriate or excessive radiation 
          occurring during CT examinations or radiation therapy: 
               1.        Person making report, job title, contact 
               information
               2.        Date(s) of event
               3.        Facility information
               4.        Radiation generating equipment specifics 
                    (i.e. manufacturer, model number, and software 
                    version)
               5.        Radiation generating equipment settings
               6.        Operator's name
               7.        Patient's physician name and contact 
               information
               8.        Copy of physician's order for CT or 
               radiation therapy treatment plan
               9.        Explanation as to reason for reporting event
               10.       Copies of internal investigation reports 
                    (include cause and corrective action to prevent 
                    reoccurrence)
               11.       Patient dose calculations (include 
               methodology)
               12.       Copies of letters sent to the patient and 




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               physician.

          Prior legislation
          SB 1237 (Padilla) Chapter 521, Statues of 2010, requires 
          health facilities and clinics that use imaging procedures 
          that involve computed tomography (CT) X-ray systems for 
          human use to record the dose of radiation on every CT study 
          produced during a CT examination.  Requires facilities that 
          furnish CTs to be accredited, and to report to the 
          Department of Public Health (DPH) an event in which the 
          administration of radiation results in an overdose, as 
          specified.
          
          SB 148 (Oropeza) Chapter 169, Statutes of 2009, requires a 
          facility that operates a mammogram machine to post notices 
          of serious violations, as defined, in an area that is 
          visible to patients.

          AB 929 (Oropeza) Chapter 427, Statutes of 2005, requires 
          the RHB to adopt regulations regarding quality assurance 
          standards for facilities using specified 
          radiation-producing equipment and to provide the 
          regulations to the Health Committees of the Assembly and 
          the Senate on or before January 1, 2008.
          
          Arguments in support
          AdvaMed argues SB 38 is needed to allow the regulatory and 
          clinical communities' time to prepare and be in full 
          compliance with the reporting requirements enacted in SB 
          1237.  The California Hospital Association writes that SB 
          38 would provide sufficient time to determine the 
          appropriate reporting standards and requirements for 
          hospitals and radiology facilities. 
          
                                     COMMENTS
           
             1.   Adverse events and radiation errors.  In response 
               to growing evidence concerning the prevalence and 
               seriousness of preventable medical errors in health 
               care facilities, California enacted legislation in 
               2006 (SB 1301-Alquist, Chapter 647, Statutes of 2006). 
                SB 1301 requires general acute care hospitals, acute 
               psychiatric hospitals, and special hospitals to report 
               27 nationally recognized adverse events to DPH and 
               requires DPH to make information regarding reports of 




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               substantiated adverse events readily accessible to 
               consumers throughout California.  
          
               SB 1237 (Padilla) includes language requiring the 
               reporting requirements for inappropriate or excessive 
               radiation occurring during CT examinations or 
               radiation therapy to include information regarding 
               each substantiated adverse event, as defined in Health 
               and Safety Code Section 1279.1, reported to the DPH 
               and include compliance history information.  

               The inclusion of this adverse event language appears 
               to be a drafting error and the author may wish to 
               delete this section (Health and Safety Code 115113 
               (c)).

                                    POSITIONS

           Support:  AdvaMed
                    California Hospital Association
                    California Radiological Society
                    Consumer Attorneys of California
                    One Individual

          Oppose:   None received
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