251 / 884
•
Therefore the wrong indication of the equipment
was accepted …
•
And the patient, clothes and room were not
checked with another radiation monitor
•
The patient kept the HDR source 4 days , for a
total dose of about 16,000 Gy ! ( 18 Gy
prescribed …..)
•
… and was disposed in a waste container,
without identification of the source …