709 / 1224
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