Amber Coffey

Professional Issues DOS-518

ROILS Case Study Paper

Radiation oncology is continuing to grow and evolve as innovative technology is

available. Throughout the late 1990’s to 2000’s Intensity Modulated Radiation Therapy (IMRT)
became a complex option for treatment. As technology changes so do regulations that are put in
place to ensure quality care and safety of the patients. IMRT also has changed how treatments
were tested with quality assurance measures. While there are many safety checks in place before
a treatment plan reaches the radiation therapist, human error can transpire and need to be
corrected. In 2010, the New York Times had an article about an accident with radiation therapy
treatment which resulted in death.1 This was a revelation to the public and the radiation world in
which meetings started to take place. The meeting between The American Association of
Physicist in Medicine (AAPM) and the American Society for Radiation Oncology (ASTRO)
together created the Radiation Oncology Incident Learning System (RO-ILS).

Radiation Oncology Incident Learning System (RO-ILS) is a safety tool tied to a patient
safety organization outlined by the federal Patient Safety Act. 2 The Mission of RO-ILS is to
provide a safer and higher quality of care in radiation oncology by providing shared learning in a
secure environment.2 Events are tracked into the system by more than 600 facilities; these events
are then case studies in which RO-ILS will suggest how to prevent errors and improve the field
of radiation oncology.

In this case study, the dosimetrist took a verbal order to generate a plan to 3600cGy and
entered the prescription into the electronic record. The physician’s intended prescription was
300cGy x12 fractions which =3600cGy, but the plan was generated for 180cGy x 20 fractions
which =3600cGy. However, the error was not discovered until the second week of treatment
after the 9th fraction had been given. The physician was surprised by the lack of tumor
progression after the 9th fraction was given. Upon checking the electronic medical record, the
physician noted that the daily dose was 180cGy instead of the 300cGy which was intended.

There are multiple factors which contributed to the error in this case study, one factor in
which lies within the communication between the physician and the dosimetrist. The dosimetrist
understood the correct total dosage but did not get clarification on the number of fractions or
daily dose. Although the overall dose to 3600cGy was correct, the daily dose resulted in giving
the patient less total dose per day. It is important for the dosimetrist to ask those details and not
assume when getting a verbal prescription from the physician. The Physician also needs to be
clear on their intended total dose, daily dose and number of fractions. It’s imperative to double
check to ensure the dosage is correct. Even though verbal prescription doses are given, it should
be properly documented in the patient's chart.

Which brings the second factor that contributed to the error is lack of documentation
while prescribing the treatment dose. An order either written or electronic should be documented
by the physician and signed before treatment can transpire. Standardizing the elements of a
prescribed treatment for radiation therapy would be beneficial to help eliminate human errors.
While the physician is looking over the dose distribution on the dose volume histograms (DVH),
it wouldn’t take much more to click over to the tab dose to double check it’s entered correctly. If
the physician had utilized prescribed treatment and entered his prescription instead of verbally
giving it to the dosimetrist this error could have been prevented. Even though the mistake occurs
in the prescription process, secondary checks should be made to verify the correct information is
inputted with the total prescription.

The third factor is the lack of quality assurance and verification of the plan. Although it’s
impossible to eliminate all human errors from the creating treatment plans and delivery. To
minimize the risk there should have been second-check work flows with either physics or the
radiation therapist to catch the error. At my clinical site all the plans go through a chart check by
the radiation therapist verifying details. Some examples would be anatomical location being
treated, correct prescription, that the doctor has signed the plan and treatment fields. If there was
a secondary check in place this incident may have been avoided before the first treatment.

Communication is the most key factor while clear communication is necessary in the
radiation oncology department. In this study the fractionation and daily dose was not clearly
communicated verbally to the dosimetrist by the physician. The prescription should have been
written on the prescription card or inputted into the treatment planning system for the
dosimetrist. Establishing standardized rules and regulation will help ensure quality treatment and
safety for patients and the radiation oncology department. It is important to learn from past
mistakes to minimize errors while adding new policy and procedures so the same errors do not
happen again.

References:

1. Bogdanich W, Rebelo K. A point Beam Strays Invisibly, Harming Instead of Healing.

The New York Times. https://www.nytimes.com/2010/12/29/health/29radiation.html.
Published December 29, 2010. Accessed September 27, 2021.
2. RO-ILS- American society for radiation oncology (ASTRO)- American society for
radiation oncology (ASTRO). Astro.org https://www.astro.org/Patient-Care-and-
Research/Patient-Safety/RO-ILS Accessed September 24, 2021.