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Therapy Accelerator Misadministrations in 2007
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Event
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Summary
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A patient undergoing radiation therapy received 10 of 14 fractions (25 Gy) to the wrong treatment site.
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Root Cause
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The root cause of the unplanned dose was that the left/right reverse button on the simulator was activated leading to the wrong side being treated. Treatment parameters were modified and the patient completed the remaining sessions. The original treatment verifications and routine chart checks failed to note this problem.
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Corrective Action
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Covers were placed over the left/right reverse buttons on the CT simulators rendering them inoperable. A section was added to the chart round review form for confirming intended treatment site and sidedness.
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Effect on Patient
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The facility does not expect the 25 Gy in 10 fractions to have an adverse affect on the patient.
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