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Event
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Summary
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Due to misalignment of the radiation therapy beam, a single fraction was administered to the brain of a patient rather than to the tumor site in the sinus and base of the tongue.
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Root Cause
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In the past, therapists used reference marks which were offset from the treatment site in order to level the patient. The marks would be found on the patient mask. The patient would then be shifted into position and the amount of the shift would be noted on the mask. In this case, the shift was not marked on the mask, but was included in the chart. The chart also included instructions to move the patient to align the tattoo on the patient's neck.
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Corrective Action
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The facility will no longer permit the shift technique to align the patient. The patient will be leveled at the treatment site. Alignment marks will no longer be placed on the patient mask.
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Effect on Patient
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Unknown
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Event
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Summary
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The patient was prescribed radiation therapy consisting of single fraction of 7.5 Gy. Instead the patient received two fractions of 7.5 Gy.
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Root Cause
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The double exposure was due to a misinterpretation of the patient chart/prescription. The patient had an earlier treatment at another time and another institution. The therapists did not recognize that the cumulative dose of 15 Gy included the treatment already received.
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Corrective Action
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The physician will note on the prescription page of the chart when the patient has received previous radiation treatments. The dosimetry, physics and radiation therapy staffs were reminded to carefully read the prescription.
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Effect on Patient
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Unknown
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Event
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Summary
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The patient was prescribed radiation therapy consisting of 0.50 Gy per day for 6 days for a total of 3 Gy. Instead, the patient received a dose of 6 Gy in two days.
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Root Cause
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The dosimetrist incorrectly read the prescription as 3 Gy per day. The error was discovered after two treatments.
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Corrective Action
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Chart checks will be more closely monitored and the Radiation Therapy techs will double check the prescriptions before the first treatment. An analysis team has been formed to investigate and recommend improvements.
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Effect on Patient
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No measurable changes in the patient's medical condition have occurred.
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