A scary medical error

I am not being Chicken Little and saying the sky is falling but I find this quite scary. You go for a medical treatment or receive a medication, you assume they are doing it right. I mean we all hear about medical errors and we know that there is always the possibility that you might wake up with the wrong kidney. There are lots of checks in place and lots of publicity of this. The errors are usually known immediately.

But what about this: you go for a pinpoint radiation treatment, it administers an overdose. You don't feel the symptoms right away but then turn into a vegetable and spend the rest of your life in a nursing home.

One hospital administered the wrong dose for FIVE YEARS!!! before they figured out that the machine was calibrated wrong.

What is wrong here? Lets start with better training for technicians and physicists (I used to work with physicists and just because they are really smart and have lots training, it doesn't mean they know everything - we won't talk about the nerd factory either), better communication from the manufacturers on how to calibrate, many more checks to make sure the right doses are being given.

I think this is a clear statement of just because it can be done, doesn't mean you should jump right in and start offering the treatment without ensuring everyone knows what needs to be done to administer it correctly. Five years of wrong treatments? Eek