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Sobreexposición accidental de pacientes de radioterapia en San José (Costa Rica)

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Spanish STI/PUB/1027 92-0-302799-8
178 45 43.50 2000

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This report summarizes the assessment made of an accidental overexposure of radiotherapy patients that occurred at the San Juan de Dios Hospital in San José, 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.
Contents: Preface; Executive Summary; 1. Overview of radiotherapy and radiation protection; Part I. Background; 2. History of the accident; 3. Expert Assessment organized by the IAEA; Part II. Findings of the Expert Team; 4. Assessment of the dosimetry and the status of the equipment and the facility; 5. Medical effects of radiation exposure of the patients; Part III. Conclusions and recommendations; 6. Conclusions and recommendations; Appendix I: Results of the dosimetric findings and the status of the equipment and the facility; Appendix II: Data on patients; Annex: Records on the participation of the San Juan de Dios Hospital in the IAEA/WHO TLD postal dose quality audit; Addendum: Reconstruction of the doses to normal tissue for patients with marked adverse effects.

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