Dose 2016

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) “…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

o

Utrecht 2016