The Glasgow incident--a physicist's reflections.

摘要

This Editorial represents the reflections of one physicist on the Glasgow incident. It does not represent the considered views of the Royal College of Radiologists (RCR) or the Institute of Physics and Engineering in Medicine (IPEM). It identifies some additional issues to those raised by the inspector and it may be helpful to see a different point of view. It also raises some questions about how such investigations should be conducted.On 2 February 2006, an incident was identified at the Beatson Oncology Centre in which a patient prescribed 35 Gy in 20 fractions was given 55 Gy in 19 fractions. A visit by the inspector to investigate this incident was carried out on 10 February 2006, at which most of the important issues relating to this incident were identified. A report of the incident, allowing other centres to learn from the errors made, was finally placed on the BBC web site on the morning of 27 October 2006 and is also available on the Scottish Executive web site. This very detailed and challenging report provides the data on which others, without the benefit of having interviewed those involved, will address relevant issues in their own practice.