CPB Ljubljana 2018 course book

Human Errors:

March 2013: Radiation Oncology Dept. in Germany found out that 7 cases have been mistakenly treated using HDR-BRT. This was an under-dosage for all 7 cases. After a further research in the patient files, the amount of those cases was increased to 10. It was the result of malfunction of the RTP and the resulting

faulty user operation. Further investigation:

• Manual adjustment of dwell times • wrong representation /interpretation of the dose distribution in the RTP • Manufacturer has then fixed the problem • New training and education of the staff