Description of Event or Problem · 1
A PATIENT WAS TREATED WITH A HIGHER THAN INTENDED DOSE OF RADIATION DURING A RADIATION THERAPY TREATMENT. THE PATIENT WAS TREATED WITH 291 MU INSTEAD OF THE PRESCRIBED 184 MU FOR ONE TREATMENT FIELD. THE USER NOTED THE DISCREPANT TREATMENT RECORDING AND CONTACTED IMPAC FOR ASSISTANCE. IMPAC INVESTIGATED AND DETERMINED THAT THE EVENT WAS CAUSED BY THE FOLLOWING USER ERRORS (WHICH HAVE BEEN EXPLAINED TO THE SITE): IT APPEARS THAT THE THERAPISTS DID NOT CLEAR THE PREVIOUS PATIENT'S TREATMENT FROM THE LINEAR ACCELERATOR CONSOLE (NOT AN IMPAC PRODUCT). THE THERAPISTS OVERRODE THE INITIAL MU TO BE TREATED FOR 291 MU, THE PREVIOUS PATIENT'S TREATMENT FIELD DOSE, WHICH BECAME THE NEW EXPECTED MU. THEY THEN KEYED OFF THE CONSOLE, MODED THE MACHINE TO DELIVER THE INTENDED 184 (THE CORRECT DOSE) AND TREATED. UPON CONCLUSION, THEY RECEIVED A "MU LESS THAN EXPECTED. DO YOU WANT TO DELIVER THE REMAINDER?" NOTIFICATION, TO WHICH THEY ERRANTLY ANSWERED YES AND DELIVERED THE UNINTENDED ADDITIONAL DOSE (WHICH THEY HAD ALREADY ACCEPTED BY THE OVERRIDE).