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Inappropriate commissioning
Reported 2007 at Hôpital de
Rangueil in Toulouse, France
In April 2006, the physicist in the
clinic commissioned the new
BrainLAB Novalis stereotactic unit
o
Possible to use small fields
(6x6mm)
o
“…an ionisation chamber of
inappropriate dimensions…” for
calibrating the smallest microbeams
was used (
Farmer chamber was used)
o
The incorrect data was entered into the
TPS
o
145 patients affected
Warsaw 2017
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