640 / 1138
ESTRO SBRT course Sept 2015
5
Outcome
•
205 patients were significantly overdosed (25%) with increased morbidity and possible
deaths considered as a consequence.
•
The error was not then recognised, possibly because the physicist was working
on his own
and his figures may
not have been checked
.
•
The error was detected during a national
external audit
Lessons:
•
Always independent check of manual input!
•
External reference audits are crucial