[97715214]
As required by the (b)(6) state rules and regulations, we are writing to inform you of a recent documentation error due to a defect in accuray tomography equipment software. The error did not result any patient harm or inadvertent treatment. The glitch was contained in the software and was monitored daily by staff. The accuray manufacturer resolved the issue by (b)(6) 2018 and no further issues have been reported. On (b)(6) 2017 - therapists noticed that the number of fractions reported in aria (electronic medical record) is one less than the true number of fractions reported in tomotherapy. Therapists informed physicists immediately. On (b)(6) 2017 - physicists confirmed that the rt records were not automatically exported by the ois to aria since (b)(6) 2017. Physicists exported all fractions from (b)(6) manually. The problem was reported to radoncit department and administration. At manual import of fractions it was noticed that one patient's records showed double the amount of dose actually delivered. On (b)(6) 2017 - accuray and varian customer support lines were called to assist. On (b)(6) 2017 - therapists noticed that 'elapsed days' for patients who started treatment before december 1 is about 30 days longer than the true number of elapsed days. Therapists informed physicists. On (b)(6) 2017 - accuray, varian and administration were made aware of the problem with the discrepancy in 'elapsed days'. On (b)(6) 2017 - accuray sent out a customer supplement outlining the issues described above. On (b)(6) 2018 - issue resolved by accuray. No further issues noted. Please do not hesitate to contact me for any questions or concerns at (b)(6). Cordially, (b)(6).
Patient Sequence No: 1, Text Type: D, B5