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Case 1

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A patient received a significant radiotherapy overdose despite the use of independent checks, and
verification by computer. The radiotherapy overdose occurred because the patient was receiving
palliative radiotherapy, the incorrect dose was entered into the treatment plan, and the incorrect
dose was not caught by verification methods. The incorrect dose was entered into the treatment
plan because it was calculated incorrectly (but the same) by two different radiographers working
independently. Both radiographers made the same error in their manual calculations. This particular
radiotherapy program involved two beams (whereas one beam is more common). The dose for each
beam then must be divided by two (to ensure the overall dose is as ordered). This division was not
performed, leading to a doubled calculated dose. The inquiry into the overdose found that both
radiographers used an old procedure which was confusing and not recommended by the
manufacturer of the software that controlled the radiotherapy delivery. While a new procedure had
been implemented in the last six months. The radiographers had not been trained in the new
procedure.

Once the two manual calculations are performed, the treatment plan (including the dose) was
entered into the computer (by a third radiographer). If the treatment plan does not match the
computer’s calculations, the computer sends an alert and registers an error. The treatment plan
cannot be delivered to the patient until this error is cleared. The facility’s process at this point
involves bringing in a treatment planner to attempt to match the computer and calculated doses. In
this case, the treatment planner was one of the radiographers who had first (incorrectly) performed
the dose calculation. The radiographers involved testified that alerts came up frequently, and that
any click would remove them from the screen (so sometimes they were missed altogether). The
inquiry found that somehow the computer settings were changed to make the computer agree with
the (incorrect) manual calculations, essentially performing an error override. The inquiry found that
the radiographers involved in the case believed that the manually calculated dose was correct, likely
because they didn’t understand how the computer calculated doses (not having had any training on
its use) and held a general belief that the computer didn’t work well for calculating two beams.