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Unintended Exposure of Patient Lisa Norris During Radiotherapy Treatment at the Beatson Oncology Centre, Glasgow in January 2006.

Johnson AM. Edinburgh, Scotland: Health Department; 2006. ISBN 0755962974.

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November 22, 2006
Johnson AM. Edinburgh, Scotland: Health Department; 2006. ISBN 0755962974.

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.

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Johnson AM. Edinburgh, Scotland: Health Department; 2006. ISBN 0755962974.