Publication #5857
Reference
Name
Unintended overexposure of a patient during radiotherapy treatment at the Edinburgh Cancer Centre, in September 2015
Categories
Scottish Government
Organization
Scottish Government Health and Social Care Directorates
Keywords
NHS
SCOTLAND
CANCER
TREATMENT
RADIOTHERAPY
RADIATION EFFECTS
MEDICAL ERRORS
EDINBURGH CANCER CENTRE
Description
Between 14th September 2015 and 18th September 2015, a patient received a dose of ionising radiation much greater than that intended while undergoing a course of radiotherapy at the Edinburgh Cancer Centre (ECC) in Scotland.
This report, by the Inspector warranted by the Scottish Ministers for the IR(ME) Regulations, records the findings of the incident investigation. It identifies the errors that caused this overexposure and includes consideration of the deficiencies that contributed to the errors and where responsibilities for these deficiencies lay. It also makes recommendations intended to minimize the possibility of recurrence of any similar errors and to enhance patient safety in radiotherapy more generally.
This report, by the Inspector warranted by the Scottish Ministers for the IR(ME) Regulations, records the findings of the incident investigation. It identifies the errors that caused this overexposure and includes consideration of the deficiencies that contributed to the errors and where responsibilities for these deficiencies lay. It also makes recommendations intended to minimize the possibility of recurrence of any similar errors and to enhance patient safety in radiotherapy more generally.
Contact Name
Person-Centred and Quality Team
Contact Email
Contact Address
Created
2016-07-08 00:00:00
Download URL
External Link: http://www.gov.scot/Publications/2016/07/8854
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