A major Sydney Hospital was confronted with a longstanding and complex Chemotherapy under-dosing claim with media and political scrutiny. A twelve months project was undertaken to deal with the multiple factors involved. These included matters such as painstaking record review, meticulous patient support, overhaul of Chemotherapy prescribing techniques, new systems of monitoring of prescribing, recording of variations in dosage with consultation, MDT upgrades and audits and communication systems improvement, A key issue identified was the need for improvement in staff culture and measures were introduced to produce change. This presentation will discuss the methodology used and the impact of this project on the hospital and its staff and patients.