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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
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2016-10-05
T Knöös