2016 Risk Course Book

34

What went wrong and how it was detected?

 The physicist may have multiplied by the wrong factor to achieve an equivalent exposure for one full minute. Tragically, this inaccuracy was not then recognised, possibly because the physicist was working on his own and his figures may not have been checked. o Or it was checked and what was noticed was what was expected

 Commonly only relative dosimetry may follow

 As a result of a calibration error, 205 patients were significantly overdosed (25%) with increased morbidity and possible deaths considered as a consequence.

 Institute of Physical Sciences in Medicine performed a National multicentre comparison of dosimetric consistency - External Audit

2016-10-05

T Knöös