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Kristen Dezell
October 30, 2022
DOS 518 - Professional Issues
Radiation Oncology Incident Learning System (RO-ILS) Case Study
Introduction
Highly complex radiation treatment plans require increased complexity in the dosimetric
planning and therapeutic radiation delivery workflows. While the vast majority of radiation
treatments are delivered safely and effectively, there have been incidents reported as treatment
errors resulting from random errors, stress in the work environment, and implementing new
technology.1 In 2011, the American Society for Radiation Oncology (ASTRO) and the American
Association of Physicists in Medicine (AAPM) established a reporting system to share incidents
and allow multi-institutional learning in a non-punishable and safe environment, entitled as the
Radiation Oncology Incident Learning System (RO-ILS).2 This system promotes high quality
patient care through shared learning at a nationwide level, with the goal to reduce future unsafe
incidents with repetitive potential. As a medical dosimetrist, the integration of daily safe
practices is vital and can be accomplished through anticipatory treatment planning features along
with proactive communication with physicians and medical physicists. The following case was
reported to the RO-ILS and will be evaluated from a medical dosimetry perspective to discuss
factors contributing to the error and recommendations to prevent the error from occurring in the
future.
Case Three: Wrong vertebral body treated
One fraction out of 45 fractions was treated to the wrong vertebral body. The patient was
aligned in a stereotactic body fix system to tattoos that were the three point alignment. The
therapists made daily shifts from the tattoos to isocenter. The patient was aligned in the room and
daily shifts were made. The stereotactic system requested a shift of 2.5 cm in the sup/inf
direction which was performed by the therapists. A CBCT was performed and a -0.4 cm
correction was made in the sup/inf direction. The total offset from the correct isocenter was 2.1
cm. The error was caught by an offline physician reviewing the CBCT images and noted that the
wrong vertebral body was treated.
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Discussion
Based on the fractionation regimen of this case, the patient received 180 cGy to the
wrong anatomic location, causing a reportable treatment error. From a dosimetry perspective,
there are multiple factors that could have led to this unfortunate error. First, patient movement is
a complexity that should always be watched and considered, leading to the importance of the
audio and visual monitoring system throughout treatment. While planning target volume (PTV)
margins account for some daily positional variation, the margins are not large enough to account
for a large 2.1 cm shift as in this case. Adding to setup uncertainties, daily manual shifts from
the user origin allow an opportunity for human error and a potential geometric miss of the target.
Indexed immobilization can help in regards to more reliable patient positioning, and shift
automation can reduce random human error in daily shift calculations.3 My clinic has
implemented a couch “delta” shift function in the Eclipse treatment planning system (TPS) that
automatically moves the treatment couch to the correct shift location after initial patient setup.
Therapists then visually verify the automatic shifts in the room prior to imaging, practically
eliminating the chance of random human error in this area of daily setup.
Daily setup factors begin at simulation, with the patient being 3-pointed as close as
possible to their disease site or vertebral level. Once the simulation scan is reviewed for
planning, the dosimetrist should take a moment to consider the possibility of maintaining a
simple 3-point setup, without shifts, to eliminate the complication of manual shifts.
Nevertheless, there are many reasons shifts may be necessary for a plan. If needed, the
dosimetrist should simply make sure to document the direction and magnitude of all shifts in a
daily setup or alert note requiring a therapist to review and sign for each treatment. In addition, a
dosimetrist could add target and OAR contours onto the digitally reconstructed radiograph
(DRR) for the therapists to have more anatomic references during imaging localization.
Another key factor leading to the error in this case relates to proper communication
during the imaging process. The workflow of this case does not explicitly state all imaging
specifics, but perhaps there was a lack of sufficient imaging. Vertebral treatments should require
images to reduce the chance of a geometric miss through counting vertebrae using prominent
bony landmarks.4 Regarding vertebral counting for a cervical treatment, imaging should include
the base of skull or the first rib; a thoracic treatment should include the first rib or last rib; and a
lumbar treatment should include the last rib or sacrum to properly count vertebral bodies and
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ensure correct treatment localization. Having at least two therapists visually and verbally agree
on the correct vertebral level maintains confidence in treating correctly and safely.
Along with proper imaging, standards of practice (SOP) should include having two
therapists to verify alignment and vertebral counting to reduce the chances of human error. To
further help with daily localization, imaging should include a kV/kV orthogonal pair for initial
alignment combined with a CBCT to evaluate nearby soft tissue landmarks. Every vertebral
treatment SOP should not allow a shift more than 2 cm without a physician signoff. A shift more
than 2 cm should be an automatic mental alert to the therapists that potentially there is a setup
issue or problem with the localization process. Proactive communication with fellow therapists,
the physician, and medical physicists along with procedural pauses are very helpful to eliminate
this issue. Furthermore, it is important that each facility recognizes the need to allow enough
time for imaging before each treatment in order to maintain the highest quality of safe patient
care. In this case, it is possible that the therapists were in a rush in order to maintain a high daily
workload. Preserving a comfortable and supportive work environment is essential in promoting
high communication amongst all staff.
In conclusion, medical dosimetrists can help reduce future treatment errors through
sufficient treatment planning features and ample communication throughout the patient’s care
team. The previously mentioned processes have been implemented in my clinic for all vertebral
treatments. This includes analyzing the impact of daily shifts, including ample contours within
imaging DRRs; ensuring enough bony anatomy is included on all DRRs for vertebral counting;
training students and new staff about the vertebral 2 cm shift SOP; and completing a procedural
pause with the physician during plan check, at the first treatment, and during any uncertainty of
shifts at any point of any treatment. Maintaining high levels of communication and teamwork
are essential in delivering safe and effective radiation treatments. Learning from others through
RO-ILS provides an encouraging opportunity for multi-institutional discussion and growth in
maintaining safe treatment practices and high quality patient care policies.1
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References
1. Clark BG, Brown RJ, Ploquin J, Dunscombe P. Patient safety improvements in radiation
treatment through 5 years of incident learning. Pract Radiat Oncol. 2013;3(3):157-163.
https://doi.org/10.1016/j.prro.2012.08.001
2. Hoopes DJ, Dicker AP, Eads NL, et al. RO-ILS: Radiation oncology incident learning
system: a report from the first year experience. Pract Radiat Oncol. 2015;5(5):312-318.
https://doi.org/10.1016/j.prro.2015.06.009
3. Sueyoshi M, Olch AJ, Liu KX, et al. Eliminating daily shifts, tattoos, and skin marks:
streamlining isocenter localization with treatment plan embedded couch values for
external beam radiation therapy. Pract Radiat Oncol. 2018;9(1):110-117.
https://doi.org/10.1016/j.prro.2018.08.011
4. Murphy MJ. Intrafraction geometric uncertainties in frameless image-guided
radiosurgery. Int J Radiat Oncol Biol Phys. 2009;73(5):1364-1368.
https://doi.org/10.1016/j.ijrobp.2008.06.1921