Steven Yorio

DOS 518
10/10/21
Case Study One

In this case study scenario, the physician gave a verbal order to the medical dosimetrist to

generate a plan with a total dose of 3600 cGy and the dosimetrist entered it into the patient’s

electronic medical record. The physician’s intent was to prescribe this dose to the patient in a

fractionation pattern of 300 cGy in 12 fractions. The medical dosimetrist assumed that the

physician desired 180 cGy in 20 fractions. The physician approved the plan, and it was exported

to the treatment unit. It was not until the patient’s second week of treatment that this error was

realized when the lack of tumor regression caused suspicions to arise. Upon checking the

medical record, it was discovered that the incorrect fractional dosage was being administered to

the patient.

The error pathway began when the medical dosimetrist accepted the verbal order to enter

the radiation prescription into the patient’s chart without clarifying the fractionation scheme that

was intended. Physicians tend to get very busy and can sometimes be overwhelmed when

juggling new patients, consults, contouring, approving plans, emergent treatments, dictation,

monitoring current treatments, insurance authorizations, etc. This does not excuse a default from

the hierarchy of roles within the radiation oncology department. There are reasons why

physicians are required to perform certain tasks for the patients they are treating, and this is a

prime example. The medical dosimetrist did not know the fractional dosage the physician was

contemplating, they simply conjectured that it would be a standard fraction pattern due to the

lack of instruction. Both parties are wrong in this case since the vagueness of the order and the

absence of follow-up and clarification led to the patient being mistreated.

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 Steven Yorio
DOS 518
10/10/21
A study by Blakaj et al. evaluated the causes of communication errors in radiation

oncology and found that written errors accounted for 62% and verbal errors cause 32%. Of these

errors, an absence of communication or miscommunication were the prime cause in 50% and

21% of these events respectively.1 This study also found that that most often the radiation

oncologist was the most common cause of communication errors which is to be expected as the

patient treatment plan begins with physician orders. An error at this level is bound to cause a

trickle-down effect through the rest of the radiation oncology department and lead to errors in the

patient’s treatment. In this case, the mistaken fractional dosage was undoubtedly the result of the

physician’s omission of direction to the medical dosimetrist.

The medical dosimetrist is not free from fault in this situation either. When working in a

clinical setting as a dosimetrist, therapist, technologist, or anyone else who acts at the behest of

physician orders, it is important to never make assumptions about a patient’s treatment and

subsequently submit documentation that determines the course of treatment without written and

signed backing by the physician. Even if there is no legible order signed by a medical doctor in

the patient’s chart, there must be evidence of physician communication of the desired radiation

prescription and fractionation pattern. If this evidence is absent, then the person who entered the

information to start a course of action for this patient is at fault.

Another responsible party in this mistake is the physicist. If they had performed the

quality assurance and checked the patient chart properly then this lack of physician approval may

have been caught before being sent to the treatment machine. This entire situation is the result of

human error, and there is nothing technical about it. Generating a treatment plan is a complex

process and there are many parties involved along the way, thus there are many steps at which

mistakes can be made. Therefore, an extensive quality assurance program is needed to check and

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DOS 518
10/10/21
recheck every aspect of a treatment plan as it is being finalized. The risk of human error can be

greatly reduced by implementing this requirement.2

A way this situation may have been prevented is by only allowing exportation of the plan

to the treatment machine with a physician signature. With there being so many moving parts in

the creation of a plan, there should be reassurance that the original intent of treatment was not

lost along the way. It should be required that a plan does not get sent through to treatment

without a written and signed directive from the ordering physician. Another way this could have

been prevented is if the dosimetrist is prohibited from generating a plan without a signed order

from the physician instead of merely stating their intent. If the physician is required to put a

written prescription in simultaneously with their target structure contours, this entire situation

could have been prevented.

In conclusion, written documentation is of paramount importance when generating

treatment plans. If the proper checkpoints are in place to require the appropriate approval from

all parties involved, it may ensure a smooth and safe transition from prescription to planning to

treatment. Verbal orders should be discouraged due to the strong potential of miscommunication.

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 Steven Yorio
DOS 518
10/10/21
References

1. Yeung TK, Bortolotto K, Cosby S. et al. Quality assurance in radiotherapy: Evaluation of

errors and incidents recorded over a 10 year period. Radiotherapy and Oncology.
2005;74(3):283-291. http://doi.10.1016/j.radonc.2004.12.003

2. A. Blakaj, L. Wootton, J. Zeng, et al. Let’s talk: communication errors in radiation

oncology. Red Journal. 2017;99(2S):3300. University of Washington Medical Center,
Seattle, WA. https://www.redjournal.org/article/S0360-3016(17)32968-1/pdf