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Human Errors:
March 2013: Radiation Oncology Dept. in Germany found out
that 7 cases have been mistakenly treated using HDR-BRT.
This was an under-dosage for all 7 cases.
After a further research in the patient files, the amount of
those cases was increased to 10.
It was the result of malfunction of the RTP and the resulting
faulty user operation.
Further investigation:
•
Manual adjustment of dwell times
•
wrong representation /interpretation of the dose
distribution in the RTP
•
Manufacturer has then fixed the problem
•
New training and education of the staff