Dose Course 2018_Flipping book

Identification

Cause of the accident

Consequence

Number of patients involved

Major RT accidents

USA (1974-1976)

Wrong decay curve for Co-60

Overdose (up to 50%)

426

Double correction of MU by ISQ after the implementing a new TPS. Error in the calibration of a Cobalt unit. Misunderstanding of the time units (0.3 minutes were taken as 30 seconds instead of 18 seconds) Forcing a fifth block in a TPS that admitted four as a maximum Software of an old accelerator was incorporated in a new accelerator. Errors in modality and energy. Two faults in two circuits at the same time + inoperative interlock lead to the accelerator operating with an ineffective beam monitoring system. After changing a cobalt source all files except one (dose calculation with trimmers) were actualised in the TPS. One new doctor decided treating patients with the trimmers. Treatment time was calculated using the dose-rate of the old source After a breakdown of a linear accelerator a company technician repaired it. However a meter display indicated an energy selection problem. This indication was disregarded. All patients treated with electron beams were

UK (1982-1990)

Underdose (5-30%)

1045

Costa Rica (1996)

Overdose (up to 60%)

115

Entrance in vivo dose measurements

The time was doubled. 100% overdose.

Panama (2000)

28

USA and Canada (1985-1987)

6 (3 of them died)

Overdose (doses in one fraction of 80-100 Gy)

Poland (2001)

5

USA (1987-1988)

Overdose (up to 75%)

33

Spain (1990)

Overdose

27

treated with the maximum available electron energy.

TPS calculation performed with static wedges while the patient was treated with dynamic wedges

France (2004- 2005)

Overdose (by 7%-34%)

23