1516-1517 / 2001
•
Therefore the wrong indication of the equipment
was accepted …
And the patient clothes and room were not
•
,
checked with another radiation monitor
h i
k h
d f
•
T e pat ent ept t e HDR source 4 ays , or a
total dose of about 16,000 Gy ! ( 18 Gy
ib d )
prescr e …..
•
The catheter with the source felt at that time
with necrotic tissues,
•
… and was disposed in a waste container,
without identification of the source …