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ROILS Assignment Case 1

Hieu Tran

UWL Medical Dosimetry

DOS 518 Professional Issues in Medical Dosimetry

October 24, 2023

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As treatment techniques and technologies in the field of radiation oncology become

progressively complex and rapidly evolving, it is important to recognize, prevent and minimize
the errors that arise when treating patients with radiation. Incident learning systems (ILS) are an
vital quality improvement tool to address these errors and have been used effectively and
efficiently to identify and reduce incident rates by training staff and improving processes and
technologies.1 The Radiation Oncology Incident Learning System (RO-ILS) is an ILS that
launched in 2014 and includes over 825 participating facilities to date.1 The goal of RO-ILS is to
shared learning of reported incidents to improve the safety and quality of radiation oncology
care.

The case being analyzed was logged into RO-ILS system is about the medical dosimetrist
generated an incorrect prescription of 180cGy x 20 fractions based on an ambiguous verbal order
of 3600cGy total dose, instead of the correct 300cGy x 12 fractions. The main problem caused in
this case is that the intended fractionation was not communicated effectively and accurately from
the radiation oncologist to the medical dosimetrist. The plan and prescription were then approved
by the radiation oncologist, and this issue was not discovered until the 9th fraction when the
tumor was not regressing as expected. In this case, there were several points in the workflow trail
that could have potentially caught this error. Unfortunately, there was oversight at multiple levels
and lack of completion of certain roles and responsibilities that have caused this to fall through
the cracks. The patient’s care ultimately suffered as the result of a preventable medical error.
Miscommunication and having an inadequate process are two contributing factors that lead to the
misadministration of radiation with the wrong daily dose being delivered to the patient.

Starting from the very beginning, or the root cause of the error, is the lack of documented
prescription directly from the physician. Verbal orders are prone to create error, since one can
only rely on accuracy of momentary communication. Using only verbal communication as a
means of conveying prescription intent by the physician led to an assumption and
misinterpretation of information that contributed to the medical error and harmed the patient.
One action that can be used to prevent a similar situation in the future would be to use another
form of communication in conjunction with the verbal style that was used. For example, a
written directive can be used to convey the doctor’s intent. Using a written form of
communication can alleviate some misinterpretation and can be referred to for more clarification
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by multiple parties even if they are not present for the verbal communication that has taken
place. Also, if the written directives were standardized or using standardized templates, this
would allow continuity between different physicians and the treatment planning department.
After the physician creates a written order, the dosimetrist would then be able to follow
instructions and create a plan with the desired written prescription with confidence and accuracy.

It is the role of the physician to enter the prescription accurately, so that the correct
information is conveyed to the planner. In addition, the physician did not verbally specify the
fractionation scheme for the total dose of 3600cGy, and that is a crucial aspect that should not be
assumed by the dosimetrist. This further highlights the importance of having a well-documented
prescription with all the information necessary prior to planning. Ultimately, the physician had to
review and approve the plan and prescription. This was another check point or opportunity for
the error to be caught and fixed prior to treatment delivery. Typically, courses of treatment are to
be documented to show the prescription, dose distribution, and dose to regions of interest at
minimum. When the radiation oncologist is ready to “sign” the plan and approve it to be
delivered, they must go through the document for its accuracy. The physician should not only
look at the plan but also must sign off on the dose prescription of the plan as well. Another check
is the staff of the medical physics department should also double check the prescribed treatment
as another layer of defense so an unintended dose will not be administered to a patient.

A process that could be put in place would be for a patient to be seen by the physician
within the first week of treatment. This would allow for an error to be caught sooner and
hopefully a correctable action can be used to minimize harm and still give the patient an
appropriate therapeutic dose. An adjustment from 180cGy/fraction to 300cGy/fraction is a
significant difference and would have great impact on the biological effective dose (BED) of the
plan, and thus the dose constraint of the organs at risk as well. Compromising the desired effect
ultimately degrades the quality of treatment. Being able to recognize the wrong fractionated dose
being delivered to the patient sooner can minimize the extent of this error.

Several actions can be taken to resolve this case and be used as a chance for the
improvement of plan’s quality, secondary check, and departmental procedures. The issue is
certain responsibilities, such as prescription filing was done by a dosimetrist instead of
physician, and that the plan was not carefully reviewed for approval. This can be a result of
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larger, more systemic liabilities in the department, such as understaffing, inadequate training of
staff, lack of established workflow protocol, and unclear roles/responsibilities. These systemic
issues can be caused by the lack of standardization of protocols, which may lead to confusion.2
Standardization of protocol and workflow should be communicated and documented for access
and training.

Errors that are found such as in this case can be identified, investigated, and analyzed for
the root cause. It is the first step to preventing similar instances from occurring in the future.
Implementing continuous quality improvement can be done by forming a team that aims to
identify the problem, prioritize safety, define measures of success, brainstorming ideas and has
knowledge of where the system needing improvement. This way, this small representative group
can identify the safety issues, prevent harm to patients, and implement quality improvement
processes to prevent potential similar harm in the future. It is important for this group as well as
the whole department to recognize that this is not an individualized issue due to one or two
persons, but rather an issue of the process itself; this incidence is just evidence that quality
improvement could be implemented.3

In this case of the planner who wrote the inaccurate prescription for the physician to sign
was unfortunate and these types of mistakes should be thoughtfully analyzed for ways to
improve upon or create new processes and to educate staff to prevent similar error. Departments
should instill a culture of accountability and continue to assess processes and always work to
improve upon them. Prevention methods at the beginning of the planning work process can
include simple implementation of requiring physicians to write in the full prescription and
fractionation information in an electronic document along with constraints of normal tissue.
Prevention at the end of the planning work process can include performing chart rounds for new
starts to evaluate that plans are safe and as intended. In case preventable method do not work,
departments should also implement a quality control process or standardization to amend errors
efficiently so that everyone is clear about their roles instead of having confusion or uncertainty. 3
This may involve creating a flow chart of action plans. Flow charts can be more explicit to
include what needs to be documented, and which activity is performed by who. The flow charts
may also highlight the need for additional staff education and training. Creating a flow chart of
the process can have considerable potential benefits that include staff understanding the process
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much better, used for training aid, and staff beginning to take ownership of the process by taking
part in the activities. With a clear and standardized process, errors like this case could have been
caught and averted.
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References

1. Radiation oncology incident learning system (RO-ILS). American Society of

Radiation Oncology (ASTRO).
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS. Access
October 20, 2023
2. Safety is no accident: a framework for quality radiation oncology care. American
Society of Radiation Oncology (ASTRO).
https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and
%20Research/PDFs/Safety_is_No_Accident.pdf . Published 2012. Accessed October
20, 2023
3. Lenards, N. Continuous Quality Improvement. [Soft Chalk]. DOS518 Professional
issues; October 24,2023; University of Wisconsin La-Crosse