Accidental overexposure of radiotherapy patients in San Josť, Costa Rica, Volume 1997
This report summarizes the assessment made of an accidental overexposure of radiotherapy patients that occurred at the San Juan de Dios Hospital in San Jose, Costa Rica, in August and September 1996. The assessment was carried out by an Expert Team convened by the IAEA in July 1997 at the request of the Government of Costa Rica. The findings of the Expert Team's assessment are presented in two parts: (1) an evaluation of the doses to patients by analysing the treatment records and physical measurements; and (2) a medical examination of patients, together with the autopsy findings for those who died. Thirty cross-sectional images are reproduced that show the dose reconstructions made for some of the patients. The purpose of the report is to foster information exchange with a view to preventing similar accidents in the future.
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OVERVIEW OF RADIOTHERAPY
HISTORY OF THE ACCIDENT
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1996 Prescribed dose 1elvis 25 fractions abdominal adverse effects Alcyon August autopsy beam biologically equivalent bowel brachytherapy Breast cancer calibration carcinoma Cause of death cervix chemotherapy clinical cm Estimated dose cm Findings Conclusions Costa Rica Date of death Dates of therapy diarrhoea Dios Hospital Dmax dose per fraction dose quality audit dose rate dosimetry E-mail epilation Estimated dose Expert Team fibrosis five fractions fractions Findings Gy Findings Gy per fraction HSJD IAEA IAEA/WHO TLD postal irradiation Juan de Dios July lumbar spine metastases neck necrosis number of fractions old source overexposure Identification Pelvis postal dose quality radiation accidents radiation effects radiation exposure radiation therapy radiotherapy received rectal rectum result of overexposure San Josť San Juan September 1996 Prescribed skin source change source Findings spinal cord surgery Table TLD postal dose total dose Tumour history ulceration user stated dose Yes Yes Yes