PNO-IV-98-058, on 981125,medical Misadministration Occurred. Event Involved Nucletron Afterloader with Ir-192 Source. Brachytherapy Dosimetrist Entered Wrong Starting Position, 1500 Mm Rather than Intended 1450 Mm.Nmss Has Been Informed: Revision history

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13 November 2020

5 November 2020

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