Incident: Multi-leaf collimator shaping was lost when the computer rebooted several times during the transfer of the head and neck plan from the planning system to the treatment machine. Multi-leaf collimator positions were erased, leaving open fields for treatment. The patient received seven times the planned amount of radiation.
Patient: 43-year-old male
Result: Acute- swelling of head and neck, severe pain, nausea, loss of taste, difficulty swallowing; Late- loss of most vision, degenerated hearing, degenerated balance, died two years later
Location of incident: St. Vincent’s Hospital Manhattan, New York City
Explain how therapists treating this patient may have treated this patient unaware. Then, discuss at least two new strategies/policies that may have been adopted by St. Vincent’s following this incident to prevent similar incidents in the future.
