2016 Risk Course Book

42

Looker further – Calibration of TPS – Australia

 The incident was discovered in 2006 when an independent measure of machine output, external to the linear accelerator quality assurance process, was performed to implement some new quality assurance software.

 These measurements highlighted that there was an under-dosing of 5% when they used data from TS3.

 Further investigation at the time of the detection of this anomaly was able to trace back to the TPS beam calibration ratio as the likely cause of the consistent 5% dose discrepancy.

 It involved 869 patients between 2004 and 2006.

Menu

2016-10-05

T Knöös