Tenzin Yiga

DOS-518 Professional Issues

RO-ILS Case 1: Planner wrote prescription for the physician to sign

Radiation can be both extremely beneficial for cancer care and also very dangerous if the
appropriate measures are not taken to protect patient safety. Human error can cause catastrophic
workplace accidents. An error usually occurs when certain processes do not occur in the way it
was intended and most frequently occur when steps are omitted from the process.1 In June 2011,
the establishment of the national radiation oncology-specific incident learning system was
approved by American Society for Radiation Oncology (ASTRO). This incident learning system
was proposed to provide shared learning across all radiation oncology institutions with the
intention to promote and improve the safety and quality of radiation oncology. Together with the
American Association of Physicist in Medicine (AAPM) the Radiation Oncology Incident
Learning System (RO-ILS) was launched in 2014. The guiding framework for the data elements
are pulled from the Consensus recommendations developed by the AAPM Work Group on
Prevention of Errors in Radiation Oncology.2
Case 1 from the RO-ILS pertains to a situation where the dosimetrist took a verbal
prescription of 3600 cGy from the physician and entered it into the electronic medical record.
The issue that occurred because of the process was a discrepancy between the physician’s
intended dose fractionation and the fractionation the patient was receiving. The physician
intended for the patient to receive 300 cGy x 12 fractions= 3600 cGy but the dosimetrist had
input 180 cGy x 20 fractions= 3600 cGy. The plan was approved and the error was not caught
until after the 9th fraction was already delivered to the patient and the physician noticed the lack
of tumor regression.3
From this case, it is clear that one of the contributing factors was the was a lack of
communication.3 This was due to the lack of clear documentation, the verbal send off of the
intended prescription included the the total prescription dose but did not offer the intended
fractionation, which then might be interpreted as a standard dose fractionation of 180 cGy per
fraction. Prescription documentation acts as important step because it provides exactly what the
physician wants for the patient. It provides details about various parts of treatment such as dose,
fractionation, site, technique, imaging, and etc. The second contributing factor was the plan
approval step by the physician. This is a secondary check of the plan, once the dosimetrist thinks
the plan is good, it is sent to the physician for review and approval. The physician should not
only review the plan but review the data input as well which displays details such as dose per
fraction, total fractions, total dose, normalization, and etc. The information should match with
the prescription (or can be adjusted by the physician) and this step was missed by the physician,
this should have been the where that the error was caught and the wrong plan would have never
been sent to the treatment machine. Although these steps may seem simple enough, if overlooked
can result in problems as we see in this case. The tumor was not responding to the treatment as it
should have, thus acting against the patient’s care.
In order to prevent such events from occurring in the future there should be actions or
recommendations that could be put in place to enhance workflow. One recommendation is to
standardize prescriptions, this means to have a clear and concise communication of the
physician’s intent.3 There should be more details when giving a prescription, not just solely the
total dose. As stated before at my center the intent covers the site, technique, dose per fraction,
number of fractions, total dose, treatment frequency (if not intended daily), and image guidance
which is also in accordance with the “Standardizing Dose Prescription: An ASTRO white
paper”.2 The second recommendation is to regulate the process by addressing who is authorized
to write a formal prescription. It should be a departmental policy that only the physician has the
right to do this initial drafting of the prescription. This allows for change during planning but a
concrete idea of the physician’s initial intentions.3 Along with this step, I think that if there is any
confusion or if the person receiving this document finds any potential error then a follow-up with
the physician should be requested. There are times where the dose per day and number of
fractions do not add up to the total dose noted on the prescription, this needs to be addressed
directly with the physician and one cannot assume the physician’s intent. Also if you notice a
fractionation you are not familiar with, it doesn’t hurt to double check with the physician. They
can then verify with you if that was intended or an error on their part which I have had happen
before.
Although it may be impossible to completely be rid of medical errors, it is important that
we promote safe practices to prevent as many as possible. In my time as a radiation therapist, I
know first hand all the steps and measures we take to provide quality patient care. Starting from
my role in their treatment planning scan down to delivering the treatment. There are various
steps to every process but these steps are done so that things don’t get overlooked and details
don’t fall through the cracks. As stated before, errors are more likely when steps are omitted
from the process. It is important that all departments have a clear checklist and all personnel are
properly informed and trained to maintain the integrity of the workflow.
 References:
1. Lenards, Nishele. Continuous Quality Improvement. [SoftChalk]. La Crosse, WI: UW-L
Medical Dosimetry Program; 2019. Accessed October 11, 2020.
2. RO-ILS Background. American Society for Radiation Oncology.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS/RO-ILS-
Background. Accessed October 11, 2020.
3. Quarterly Report- American Society for Radiation Oncology.
https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and
%20Research/PDFs/ROILS-Q3_2017_Report.pdf. Accessed October 11, 2020.