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Publication - Report

Unintended overexposure of a patient during radiotherapy treatment at the Edinburgh Cancer Centre, in September 2015

Published: 8 Jul 2016
ISBN:
9781786523525

The report of a detailed investigation of an incident involving a serious overexposure to ionising radiation for a patient undergoing radiotherapy, in September 2015.

68 page PDF

2.9MB

68 page PDF

2.9MB

Contents
Unintended overexposure of a patient during radiotherapy treatment at the Edinburgh Cancer Centre, in September 2015
Page 12

68 page PDF

2.9MB

10 Actions already taken by the ECC

Treatment planning for this patient was started, but not completed, during the weekend 'on-call' period. Internal consideration of the circumstances of this incident has therefore led the ECC to review on-call staffing provisions and relevant on-call procedures. This has led to a number of changes including strengthening of on-call staffing, changes to on-call procedures, and the introduction of an additional calculation check for patients who commence their radiotherapy treatment during an on-call period.

The ECC has also undertaken a review of current practice in accordance with the 'Self Assessment Tool' in 'Towards Safer Radiotherapy'[2]


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