The descriptions of the 15 misadministrations are summarized in Attachment 1 . The most common reported human error is the transposition of coordinate settings, mainly the Y and Z coordinates. Other human errors are the selection of incorrect parameters such as treatment sites, doses, and exposure times, and failure to follow established procedures. A licensee requires two independent checks of the X, Y and Z coordinate settings before each exposure, instead of one independent check, to reduce the transposition of coordinates. Another licensee requires a minimum of three staff members to set the X, Y, and Z coordinates on the stereotactic frame to reduce the probability of transposition errors.
Treatment is administered only after the three staff members concur on the coordinate settings.
A licensee limits the conversations in the treatment room to only those required for the treatment of the patient, and restricts telephone calls in the treatment control area. These actions reduce distractions to members of the treatment team. A licensee requires the neurosurgeon, the radiation oncologist, and the medical physicist to verify the treatment plan before each procedure. The neurosurgeon and either the radiation physicist or the radiation oncologist has to be physically present during the treatment. This oversight improves procedure adherence and attention to detail.