Unintended Exposure of Patient Lisa Norris During Radiotherapy Treatment at the Beatson Oncology Centre, Glasgow in January 2006.
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.
Johnson AM. Edinburgh, Scotland: Health Department; 2006. ISBN 0755962974.