Katelyn Knoepke

DOS518: Professional Issues

RO-ILS

Radiation offers an immense benefit to many patients throughout the course of their
cancer treatment. However, the use of radiation also carries with it a risk of harm to the patient.
Safety initiatives are an important part of any radiation oncology practice. While radiation
professionals always strive for safety and quality in the care they provide, the complexities of
radiation treatment planning and delivery create a potential for errors throughout the process.
One way to promote safe practices is to examine errors that have occurred during treatment
planning and delivery, as well as non-adverse events that have had the potential to become an
error. A willingness to examine and address errors demonstrates a commitment to patient safety
within the field of radiation oncology.

To address an increased concern over the safety of radiation delivery, the American
Association of Physicists in Medicine (AAPM) and the American Society of Radiation Oncology
(ASTRO) sponsored a meeting in June 2010. The purpose of this meeting was to gather experts
to identify the causes of mistakes and create solutions to address these concerns to improve
patient safety in radiation oncology.1 At this time, ASTRO also launched an initiative known as
Target Safely which aimed to improve patient safety and reduce the likelihood of medical errors
during radiation treatment delivery.2 This initiative aimed to create a database for reporting
medical errors and safety concerns within radiation oncology known as the Radiation Oncology
Incident Learning System (RO-ILS). This database serves as a learning tool to focus on ways in
which safety can be improved within the field. This initiative demonstrates a commitment from
within the field of radiation oncology to place the safety of the patient as a top priority.

An event logged into the RO-ILS system will be explored here. This event concerns a
plan generated utilizing the wrong prescription fractionation. In this instance, the physician
provided the medical dosimetrist with a verbal order for a treatment plan. The physician
indicated a prescription of 3,600 cGy. The intention was for this dose to be delivered over the
course of 12 fractions with a daily dose of 300 cGy. The plan was instead generated with the
prescription of 3,600 cGy being delivered over 20 fractions with daily dose of 180 cGy. The
physician approved this treatment plan, and it was treated using the wrong fractionation. The
decrease in daily dose led to a lack of tumor regression that was noted by the physician after
delivery of the ninth fraction. At this point, the physician noticed the error in the fractionation
scheme.

This situation highlights an example of an error that occurred due to multiple contributing
factors. Within the field of radiation oncology, many factors can contribute to the chance of
errors throughout the treatment planning and delivery process. These include the complexity of
the disease being treated, the sophistication of the technologies used, the details of
communication amongst members of the treatment team, and the involvement of humans
throughout the process.1 The United States Nuclear Regulatory Commission (NRC) estimates
that about 60% or more of mis-administrations are due to human errors.3 This case was greatly
impacted by ineffective communication as well as human errors throughout the process.

The accuracy of the dose prescription is critical to the entire treatment planning and
delivery process. In this scenario, the verbal communication of the prescription led to an
opportunity for error through multiple causes. In this case, the desired prescription was
misunderstood by the dosimetrist receiving the order. While the physician had an intended
fractionation scheme in mind, it seems that this was not communicated clearly and effectively to
the dosimetrist. Also, it may have been transcribed incorrectly from verbal to written form, or
simply incorrectly entered into the treatment planning system. Whether the providing of a verbal
order was normal operating procedure, or if it was done to save time in this instance was not
clear from the report given. Without a written record of the intended dose prescription, there was
no reference for quality checks to utilize to ensure accuracy. Human error and inadequate
communication provided an opportunity for error in this case.

Another contributing factor to this treatment error was a lack of prescription verification
upon plan review and approval. Plan approval following physician review of the treatment plan
provides an opportunity to pause and check the accuracy of the dose prescription. This should be
performed by both the physician and the dosimetrist. A quality assurance check prior to
treatment delivery should also check the accuracy of the dose prescription. The dose prescription
was not thoroughly checked for accuracy by the physician prior to plan approval and
implementation. The physician approved the treatment plan with the incorrect prescription
entered in the treatment planning system. The lack of an original written prescription prevented
the dosimetrist from recognizing the error at this time. In addition, future quality checks were not
able to identify this error.

There are various ways in which this error could have been avoided. A written and signed
prescription offers more security in appropriate dose prescription transfer to the treatment
planning system. Providing and approving a written prescription provides an official record of
the desired prescription. If a verbal order is taken, this should be sent for approval by the
physician to ensure that the communication was accurate. Upon approval of the prescription, the
physician should take time and consideration to check that the prescription is accurate. Having a
written and approved prescription prior to planning provides a reference for others during the
quality check process prior to treatment delivery. Without this order, there would be nothing that
appears out of place to those checking the plan along the planning and quality assurance process.
A signed and verified written record of the dose prescription could have helped decrease the
chance of the wrong prescription being delivered to the patient.

Another opportunity to prevent this error would be through the use of a checklist or
procedural pause during the plan approval process. These initiatives would have enabled the
physician to catch this error before the plan was approved. A procedural pause allocates adequate
time to consider important factors that contribute to the safe delivery of the intended radiation
treatment. Multiple individuals should check the dose prescription throughout the process. The
signing of the initial prescription provides the physician the opportunity to check for accuracy.
Upon plan review and approval both the physician and dosimetrist check that the prescription
was accurately transferred to the planning system. A future quality check again provides an
opportunity to catch any error in the dose prescription. Having procedural pause processes in
place could have helped to prevent this error.

The accuracy of the dose prescription is crucial to the implementation of the desired
treatment for the patient. Time and careful consideration should be taken to ensure its accuracy.
Communication of the dose prescription in a formal written manner with approval by the
physician helps to ensure accuracy of the dose prescription from the beginning of the treatment
planning process. Building a workflow that incorporates checklists and procedural pauses
decreases the chance for errors in these important situations. This case study highlights the
benefit of examining errors to improve processes that emphasize safety.
 References

1. Hendee WR, Herman MG. Improving patient safety in radiation oncology. Med Phys. 2011;
38(1): 78-82.
2. Target Safely. American Society of Radiation Oncology. Published September 2015.
Accessed October 15, 2023.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Target-Safely.
3. Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. An international review of patient
safety measures in radiotherapy practice. Radiother Oncol. 2009; 92(1): 15-21.