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PSNet: Patient Safety Network
Book/Report

Unintended exposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006.

Johnson AM.

This report shares results and recommendations from the investigation of a radiotherapy overdose. The investigation identified contributing factors such as an inexperienced caregiver, supervision gaps, ineffective double-checks, and the misalignment of system improvements with training and documentation.