Use of group auto-sequencing on a treatment machine without doing adequate cross-checks of the individual fields on the patient.
1272323966
26-4-2010
Incorrect source activity calculation on HDR unit could have caused 10% underdose of patient.
1270682376
7-4-2010
Missing referral on inadequate instructions
1269991175
30-3-2010
Wrong positioning in spite of cone beam CT
1264378769
25-1-2010
Patient peed on floor (after chemo intake)
1258589962
19-11-2009
Patient couch height was not adjusted to correct isocentre.
1256080761
20-10-2009
Use of accessory equipment
1256080760
20-10-2009
Calculation error
1255907959
18-10-2009
Wrong registration of dose in treatment verification system
1255648758
15-10-2009
Geographic miss due to treatment with wrong isocenter caused by failure of treatment staff
1254093557
27-9-2009
Wriong dictation
1254093556
27-9-2009
Question about headrest
1254093555
27-9-2009
Archive IncidentID:1155. During the first three treatments imaging with cone-beam CT was performed. The physicist thought the headrest looked different, changed the contrast in the image and realised the headrest was not the correct one. In the treatment chart it is stated to be C, but inte the original CT CZF is used. The headrest is changed for fraction four.
1254093554
27-9-2009
Archive IncidentID:1154. At the start of the treatment there are markings on the patients fixations for positining. On the fixation these markings were wrong. The reference point had been moved after that the information was sent to the lasers. The markings on the photo are in accordance with the movements made on the CT.
1254093553
27-9-2009
MRI report states wrong level of metastasis.
1252365552
7-9-2009
Transposition of monitor units incorrect
1252365551
7-9-2009
Incorrect documentation
1252365550
7-9-2009
Missing bolus for 1 #
1247440749
12-7-2009
Pt scanned without markers in place
1247440748
12-7-2009
Pt scanned before ready for treatment - needs chemo first
1247440747
12-7-2009
Incorrect data saved on system
1245280746
17-6-2009
Change of monitor unit in the record and verify system
1241738344
7-5-2009
Portal image match made using incorrect isochecks
1241392743
3-5-2009
Archive IncidentID:1143. During a seeds implantation two already positioned seeds got caught in the needle and came back out. It was first when the implantation was finished as we understood this. this has never happened before, which led to uncertanties on how many seeds actually had been implanted in the patient. A count of the seeds are always performed, in this case only seeds left were counted, not already implanted. The treatment plan is checked and the loss of two seeds will probably not be of any consequence for the patient.
1241392742
3-5-2009
Archive IncidentID:1142. Patient treated for a metastasis of malignant melanoma on left lower leg. At the start the physician judges the margin to be too small in one direction. It is decided to increase the field with 1 cm. A correct change for the primary collimators are entered in Visir but the MLC leaves are not changed. This is found with the on-line portal imaging.
1241392741
3-5-2009
Archive IncidentID:1141. Patient to be treated to two different areas on left lower part of the leg due to malignant melanoma. When checking the treatment chart for patient set up notes it is found that if the patient is positioned as prescribed the also the right leg will be irradiated. The mistake is found before any tretment is given.
1240096745
18-4-2009
A cleaner was in treatment room with beam on while QA in process (490 MU,15 mv,10x10)
1239146340
7-4-2009
Set up from reference marks incorrect for 1 field
1239146339
7-4-2009
Incorrect FSD set at planning
1239059938
6-4-2009
kV imaging match
1239059937
6-4-2009
Calculation error treated for 1 fraction without headbase factor
1238800736
3-4-2009
No portal vision was made from the beginning to the boost in a conservative treatment on the breast
1238026735
26-3-2009
Wrong fitting of block
1237249134
17-3-2009
Double application of medial breast field
1237249133
17-3-2009
Treatment delivered after 2D-planning with wrong diameter
1236557932
9-3-2009
Mixed up setup lines and isocenter lines on the patient
1236557931
9-3-2009
Incorrect data in patient chart
1235002730
19-2-2009
one treatment session has been given at another location, the patient having erased the simulation marks.
1231719529
12-1-2009
Wrong collimator angle for aperture
1229645928
19-12-2008
Pt missed treatment due to systematic error
1229645927
19-12-2008
Electron end frame altered and mould room not informed
1229645926
19-12-2008
Incorrect FSD's
1229645925
19-12-2008
Attenuation factor for headbase not added in error
1229645924
19-12-2008
Shift from reference marks incorrect
1229645923
19-12-2008
Bolus missed off for 1 fraction
1229645922
19-12-2008
Social security number/personal code
1229645921
19-12-2008
Wrong CT dataset used
1227140320
20-11-2008
MUs input into R&V inversed in wedged beam and open beam
1226535519
13-11-2008
One treatment field treated twice
1224631118
21-10-2008
Patients arm got jammed
1224631117
21-10-2008
Mix up of patients
1224631116
21-10-2008
Wrong isocenter
1224026315
14-10-2008
Bolus missed off for 1 field for 1 fraction
1221607114
16-9-2008
Attenuation factor added in error
1221607113
16-9-2008
Caliper angle set incorrectly
1221607112
16-9-2008
Input of data incorrect
1218669511
13-8-2008
Shortage of staff performing IMRT treatment plans
1218669510
13-8-2008
Missing laser lines
1218669509
13-8-2008
Long waiting times, late referral from surgery
1218669508
13-8-2008
Calici virus
1218669507
13-8-2008
Treatment field didn't cover the palpable tumor
1218410306
10-8-2008
Shift error
1218410305
10-8-2008
Poor handwriting - input MU's as 5MU should have been 6MU's
1218410304
10-8-2008
ARIA data purge happening in dept - treatments given from memory stick - 3 pts not saved correctly
1216163903
15-7-2008
Image match error
1215991102
13-7-2008
Incorrect gantry angle for electron fields.
1214867901
30-6-2008
During off line image review the ant/post shift had been incorrectly applied 0.2cm
1214867900
30-6-2008
Collision of gantry with wing board.
1214176699
22-6-2008
Poor check of previous treatments
1214176698
22-6-2008
No information on new treatment technique.
1214176697
22-6-2008
Extending fields directly at the treatment machine.
1214176696
22-6-2008
Long waiting times for PAD as well as for radiotherapy
1212362295
1-6-2008
Set up error- no verification- linac working off memory stick.
1212362294
1-6-2008
Previous radiotherapy not reviewed by medical team
1212016693
28-5-2008
Intraoperative calibration error
1212016692
28-5-2008
Changement of the isocentre for the boost fields was not noted in the patient's chart.
1210807090
14-5-2008
Radiographer set up error
1208128688
13-4-2008
The patient was treated for one beam in TSD instead of SSD
1208128687
13-4-2008
Bad positioning of a block in addition to a multileaf collimator.
1208128685
13-4-2008
Concommitant treatment XRT and chemo
1208128684
13-4-2008
Isocentre move
1208128683
13-4-2008
Accelerator problesm after power shortage
1208128682
13-4-2008
Miss between actual applicator and the applicator the plan was created for.
1208128681
13-4-2008
Patient did not show up at start of treatment
1208128679
13-4-2008
Applicator and ring disconnected
1207869478
10-4-2008
Attenuation factor not included in calculation
1207523877
6-4-2008
Application of treatment field belonging to another patient.
1207523876
6-4-2008
One field delivered with wrong isocentre.
1207437475
5-4-2008
Right shoulder treated instead of left shoulder
1207178274
2-4-2008
Incorrect FSD used for one field on one fraction
1205799473
18-3-2008
Treatment field delivered as electronic portal image field only i.e. only a few Mus delivered.
1205713072
17-3-2008
Simulation of the left CMI, uing the dog leg technique instead of the right side.
1204503471
3-3-2008
Shift applied in the wrong direction.
1204503470
3-3-2008
IMRT-transfer error-DICOM origin shifted in error.
1204503469
3-3-2008
Incorrect shift applied
1202861965
13-2-2008
Error in monitor units calculation.
1202170764
5-2-2008
Shift error
1202170763
5-2-2008
Prescription change not picked up
1200874668
21-1-2008
Assessme tof patient prior to treatment
1200874667
21-1-2008
Missing information when moving patient from one machine to another.
1200874666
21-1-2008
Change of plan during treatment
1200874665
21-1-2008
Communication
1200874664
21-1-2008
Move from one treatment machine to another
1200874663
21-1-2008
Use of auto set up
1200010662
11-1-2008
Human error of filter
1200010661
11-1-2008
Non respect of the schedual of the treatment
1200010660
11-1-2008
Error of the table height.
1199319459
3-1-2008
Input error
1199319458
3-1-2008
Human error- auto set up- gantry colliding with couch
1196727457
4-12-2007
Patient imaged and field matched incorrectly to a collapsed vertebra.
1196727456
4-12-2007
Bolus missed off the same patient on 2 different days
1196727455
4-12-2007
Shift not applied
1196295453
29-11-2007
Wrong interpretation of verification images.
1196295452
29-11-2007
Missing papers
1196295451
29-11-2007
Mistake in erasing a changed plan from the verification system.
