Lessons to be learned from brachytherapy misadministrations

Errors in the delivery of brachytherapy treatments occur with unfortunate frequency. Studying and analyzing the causes of the errors helps identify situations and conditions that tend to increase the risk of untoward events. Such knowledge also points towards parts of procedures that might benefit the most from increased quality control measures. This report looks at preliminary results and conclusions from such an investigation. The presentation includes the retelling of several events in considerable detail with a discussion of lessons learned that apply to most practices