Misadministration of prescribed radiation dose

During a course of radiation therapy treatments, an incident involving machine malfunction or human error can result in delivering a dose other than the prescribed daily dose of radiation. The process of correcting and documenting the misadministration of prescribed radiation dose led to the creation of a department policy that has proved to be a useful quality assurance tool. Explanation of the policy and the information form is given. Incidents involving misadministration of prescribed dose during 1988 and 1989 have been reviewed and the results are presented. This paper describes the specific categories used to classify misadministrations, the frequency of occurrence for certain types of errors, and constructive quality control measures implemented to avoid recurrence of such incidents.