Dakota Sturgess

DOS 518- Professional Issues

Radiation Oncology Incident Learning System

In the early 1990s articles began to appear in the scientific literature describing the
frequency of medical mistakes that put patients at risk.1 The field of radiation oncology continues
to grow and evolve as new technology becomes available. As technology evolves, this does not
mean treatments are safer. It is important to ensure patients are treated safely. Radiation safety is
the number one priority in a radiation oncology department. Unfortunately, errors do happen, and
it is important to learn when one does happen. The American Society for Radiation Oncology
(ASTRO) and the American Association of Physicists in Medicine (AAPM) sponsor a web-
based portal called the Radiation Oncology Incident Learning System (RO-ILS). This allows
U.S- based practices access and the ability to send data to a federally listed Patient Safety
Organization.2 The mission of RO-ILS is to facilitate safer and higher quality care in radiation
oncology by providing a mechanism for shared learning in a secure environment.2

One case that was logged into the RO-ILS system included an error in daily dose and
fractionation scheme due to a verbal order from the physician to a medical dosimetrist to plan a
patient’s treatment to a total of 3600 cGy. The dosimetrist created a plan designed to deliver
3600 cGy in 20 fractions, 180 cGy per fraction. The physician did not communicate that they
wanted the plan to be delivered in 12 fraction, 300 cGy per fraction. The plan was then approved
by the physician and started treatment. After 9 fractions, the physician noticed the mistake due to
the lack of tumor regression at this point in treatment.

The main contributing factor was the lack of clear documentation and communication.
The prescription and the planning process must be written by the physician. The dosimetrist is
not supposed to input prescriptions in a patient’s medical records, this is to be done by the
physician. It is important to standardize documentation to be able to refer to. Within medicine,
miscommunication, and lack of communication standards, particularly during handoffs have
been linked to suboptimal outcomes.3 The dosimetrist understood the correct total dose but
assumed the fractionation scheme, which was not what the doctor intended. This would have
been eliminated if the doctor wrote the prescription themselves.
 Another factor that contributed to this treatment error would be that there was no double-
checks of the prescription when approving the plan. At Michigan Medicine, there is a couple
programs that can find inconsistency within the plan if something is off, such as prescriptions,
nomenclatures, reference points, plan technique, etc. Having such programs and standardizations
help the flow of treatment planning and ensures patient safety. Another check that is done is by
the therapist, this is one last check for the therapist to look through the documents and verify that
everything is provided and looks right for treatment. As a last final check, the dose scheme could
and should be observed. Though, this error would not be on the therapist, it could just be
checked. This still may have not be caught by the therapist because they would not know what
the prescription or dose regime that the doctor prescribed.

The treatment of cancer patients with radiation is complicated for several reasons: the
complexity of the disease, the sophistication of the technologies employed, the intricacies of
communication among members of the treatment team, and, the involvement of humans
throughout the treatment regimen.1 For these reasons, the practice of radiation oncology includes
several quality control steps designed to detect and correct mistakes and equipment failures
before they negatively impact the well-being of patients. Error reporting systems should be
developed in radiation therapy. There is growing interest in the anonymous reporting of mistakes
and equipment failures in radiation oncology.1 Members of a treatment team could be alerted to
problems occurring elsewhere that may be relevant to their institution. Any member of the
treatment team can declare a “Time Out”.1 Each member of the treatment team should have the
right and the responsibility to speak out if they have concerns about the plan. There must be an
understanding by all members of the team that when someone calls “time out” and asks for
clarification, it is to be respected and addressed appropriately before proceeding.1

Unfortunately, everyone is human, and errors happen. This case is a prime example of
why there is a need for the RO-ILS program. Errors like this can be reported and others can learn
from these mistakes. The root cause can be determined, and others can assess the situation and
make it better. It is critical that all members of the team have a safe and open dialogue. This will
help with the culture of the department, who ultimately, create the safe working environment.
Establishing a continuous quality improvement program is an important step to prevent and/or
minimize errors from occurring in the future.
 References:

1. Hendee WR, Herman MG. Improving patient safety in radiation oncology. Medical
Physics. 2010;38(1):78-82. https://doi.org/10.1118/1.3522875
2. RO-ILS- American Society for Radiation Oncology (ASTRO) - American Society for
Radiation Oncology (ASTRO). ASTRO - American Society for Radiation Oncology
(ASTRO). https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS.
Accessed October 6, 2021
3.  Evans S, Benedick F, Berner P et al. Standardizing dose prescriptions: An ASTRO
white paper. Practical Rad Onc.2016;6:369381. http://doi.org/10.1016/j.prro.2016.08.007