Dose 2016

Calibration of TPS - Australia

The incident was discovered in 2006 when an independent measure of machine output, external to the linear accelerator quality assurance process, was performed to implement some new quality assurance software. These measurements highlighted that there was an under-dosing of 5% when they used data from one of the linacs. Further investigation at the time of the detection of this anomaly was able to trace back to the TPS beam calibration ratio as the likely cause of the consistent 5% dose discrepancy. It involved 869 patients between 2004 and 2006.

Utrecht 2016