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Rashad Momoh

DOS 518 Professional Issues

University of Wisconsin – La Crosse

October 10, 2021

RO-ILS Assignment

Radiation therapy is a therapeutic treatment modality used to treat a wide variety of

cancer patients with curative or palliative intent. Although most treatments are delivered safely
and effectively, there have been a few incidents that have received national attention in the past
due to catastrophic treatment erros.1 In light of these unfortunate events, the American Society
for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine (AAPM)
developed the Radiation Oncology Incident Learning System (RO-ILS) in June 2014, through
ASTRO’s Target Safely program.2 Since its introduction in 2014, more than 550 United States
healthcare organizations have joined RO-ILS to provide patient safety information to the
database. The following case was logged into the RO-ILS and will be evaluated with a focus of
identifying what went wrong in the process and providing recommendations that may prevent the
mistake from occurring again.

Human errors occur within the medical field, some with greater circumstances than
others. One error that occurred recently within a radiation oncology department was completely
preventable. When creating a treatment plan for a patient, the medical dosimetrist was given the
prescription of 3600 cGy, verbally. The physician wanted the dose to be delivered in 300 cGy
fractions but the medical dosimetrist created the plan to deliver the dose in 180 cGy fractions.
The physician approved the plan, not noticing the mistake with the planned prescription. The
error was not discovered until the physician noticed that the tumor was not shrinking to the right
extent after the 9th fraction was delivered. This case had many contributing factors that caused
the error and there are many steps that can be taken in the future to prevent it from occurring
again.

One contributing factor to this medical error was that the physician gave the prescription
to the medical dosimetrist verbally without specifying the number of fractions. When the
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physician told the medical dosimetrist the dose he wanted the patient to receive, he just clarified
the total dose. He never explained to the medical dosimetrist that he wanted the dose delivered in
12 fractions. Another problem with telling the medical dosimetrist the dose verbally, was that the
prescription could be misremembered or misconstrued. The physician did not communicate the
prescription with the medical dosimetrist clearly which resulted in a medical error.

Another contributing factor to the medical error was the physician did not look over the
prescription before approving the plan. If the physician would have reviewed all aspects of the
plan, the error would have been caught before any dose had been delivered. The physician
should always check the prescription before they approve a treatment plan. To prevent this from
happening, the prescription should be checked before treatment is started, for every patient, by
the physician.

To prevent this from happening to another patient, radiation oncology departments should
have their physicians provide a written form of the prescription to the medical dosimetrist. The
prescription should be written with the total dose and the dose per fraction. This way when the
medical dosimetrist creates the treatment plan there is no confusion in how the dose is to be
delivered to the patient. Using proper documentation of prescriptions allow them to be referred
to and relooked at if confusion occurs when making the treatment plan. It also makes
communication between the physician and medical dosimetrist easier with more accurate
results.3 The prescription should always be written including the fractionation by the physician to
ensure that the right dose is delivered to the patient.

Another process that could prevent a prescription error from occurring is the use of a
checklist when a physician reviews a plan. The checklist should include looking over the
prescription, hot spot, dose volume histogram, dose to critical organs, isodose distribution etc.
When the physician has checked each portion of the plan they should mark the checklist with
their initials verifying they have reviewed it and providing documentation that they did. A study
performed by Atul Gawande, implemented surgery checklists into 8 different hospitals and it
resulted in 47 percent less deaths within the operating room.4 Checklists are an excellent way to
prevent physicians from missing important steps.4 If the physician used a checklist that reminded
him to review the prescription the medical error would not have occurred.
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Taking steps to avoid medical errors is an important part of working within the healthcare
field. If the error in this specific case was prevented the patient would have had better results and
their tumor would have reacted more to the treatment. All members of a healthcare team should
communicate and perform documentation when treating patients. When reviewing treatment
plans, physicians should go through a checklist making sure that everything is accurate.
Implementing these tools within the radiation oncology department can prevent prescription
errors like this one from occurring.
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References

1. Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Safety strategies in an

academic radiation oncology department and recommendations for action. Jt Comm J
Qual Patient Saf. 2011;37(7):291-299. https://doi.org/10.1016/s1553-7250(11)37037-7
2. Evans SB, Ford EC. Radiation oncology incident learning system: A call to participation.
International Journal of Radiation Oncology Biology Physics. 2014;90(2):249-250.
https://doi.org/10.1016/j.ijrobp.2014.05.2671
3. Madrid K. The importance of documentation in healthcare. Jewish Boston Web site.
https://www.jewishboston.com/the-importance-of-documentation-in-healthcare/.
December 30, 2016. Accessed October 5, 2021.
4. Morgera VD. Checklists can reduce fatal medical errors. HG.org Web site.
https://www.hg.org/legal-articles/checklists-can-reduce-fatal-medical-errors-19080.
Accessed October 5, 2021