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ROILS Assignment
Introduction
The field of radiation oncology often resembles a checks and balance system. Radiation
therapists, dosimetrists, physicians, and physicists work hand in hand to ensure accurate
treatment delivery. In the late 1990s, the introduction of Intensity Modulated Radiation Therapy
(IMRT) revolutionized cancer treatment. However, the complexity introduced by advanced
techniques like IMRT amplified the potential for errors in treatment planning and delivery. There
are various protocols and policies set up at treatment facilities to help limit possible variances in
treatment. There are also various organizations that encourage the safety of patients. The mission
of the Radiation Oncology Independent Learning System (ROILS) is “to facilitate safer and
higher quality care in radiation oncology by providing a mechanism for shared learning in a
secure and non-punitive environment.”1 It provides a national data base for facilities across the
country to contribute to patient safety data through an online portal.1 The ROILS data base
brings attention to previous mis treatment scenarios in hopes that the profession will learn from
them as a whole and prevent them from happening again.
ROILS Case 1
In the case presented, a dosimetrist received a verbal order to create a treatment plan
delivering 3,600 cGy. However, due to a misunderstanding, the dosimetrist generated a plan for
180 cGy x 20 fractions instead of the intended prescription of 300 cGy x 12 fractions. This error
went unnoticed during plan approval, and the incorrect plan was exported to the treatment unit. It
is unclear whether or not a physics check was completed by a physicist. The mistake was
discovered after the patient had received 9 fractions when the physician observed a lack of tumor
regression and realized the error in the prescribed dosage. A total of 1,620 cGy was delivered at
the time the error was discovered.
Medical Error and Prevention
The error pathway in this case began with a verbal order for a radiation therapy plan, a
communication method prone to misinterpretation. The dosimetrist misunderstood the intended
prescription fractionation, planning for 180 cGy x 20 fractions instead of 300 cGy x 12 fractions.
This miscommunication was exacerbated by the absence of a formalized written or electronic
order, a critical checkpoint missing in the process.
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There are a few different aspects of this case that can be addressed as a possible contributing
factor for the error in treatment delivery. The first being taking a verbal order from the physician.
The reliance on verbal communication for treatment orders is inherently risky. In this situation,
the dosimetrist had assumed the fractionation only based on the total prescribed dose. Verbal
instructions can be misheard, misunderstood, or misremembered, leading to significant
discrepancies in treatment plans.2 It should be the responsibility of the physician to input the
desired fractionation regimen. A second contributing factor in this scenario is the lack of a
consistent double check system. In complex workflows, as seen in radiation oncology, the
absence of a mandatory double-check system is a major vulnerability. Without an independent
review mechanism, errors can seamlessly propagate through the system, posing a significant
threat to patient safety. In addition, not having an individual besides the physician and the
planning dosimetrist evaluate the plan after approval could have played a role in not identifying
the error prior to exporting the plan. However, according to the article, Safety is no Accident, it is
the physician who ultimately approves generated plans, and it is presumed that all aspects of the
plan the physician agrees with.3
Actions and Recommendations
To mitigate such risks, transitioning from verbal orders to mandatory electronic order
entry systems is imperative. Electronic systems offer standardized templates and clear
documentation, eradicating the inherent ambiguity associated with verbal instructions. Direct
input from physicians into these systems not only enhances precision but also reduces the
likelihood of miscommunication, ensuring accurate transmission of treatment plans.
Furthermore, incorporating a mandatory double-check protocol within the treatment
planning workflow is a proactive step to intercept errors before they affect patients. After the
initial plan is formulated, instituting a process where a second dosimetrist, radiation oncologist,
or a peer independently reviews the plan against the prescribed dose acts as a vital safety net.
Implementing additional measures, such as chart rounds or peer reviews, where cases are
reviewed collaboratively with other physicians, further fortifies the safety protocols. Requiring
cases to be signed off by another physician before treatment or after the initial fractions
significantly reduces the chances of errors slipping through, fostering a culture of accountability
and patient-centric care. Prescriptions should be correlated to clinical treatment plan documents
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input by physicians. This ensures that anyone can review the desired prescription and assure
accuracy of dose delivery.
Conclusion
The integration of mandatory electronic order entry systems and mandatory double-check
protocols represents a fundamental shift in enhancing patient safety in radiation therapy. By
addressing the root causes of errors – communication breakdown and lack of verification – these
measures establish a robust framework for error prevention. Embracing these changes not only
mitigates the risk of errors but also upholds the ethical imperative of providing safe and effective
care to patients undergoing advanced radiation treatments. Through continuous vigilance,
education, and adherence to best practices, the field of radiation therapy can progress with a
focus on patient safety, ensuring optimal outcomes for every individual entrusted to its care.
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References
1. Quality and safety. American Association of Medical Dosimetrists. Accessed October 13,
2023. https://www.medicaldosimetry.org/resources/quality-and-safety/.
2. Verbal Order Errors Continue - Lippincott Nursing Center. NursingCenter. Accessed
October 13, 2023. https://www.nursingcenter.com/getattachment/Journals-
Articles/Medication-Safety/06_June_Verbal-Order-Errors-(1).pdf.aspx?lang=en-US.
3. Safety is No Accident: A Framework for Quality Radiation Oncology Care. ASTRO
Website. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Safety-is-no-
Accident. March 2019. Accessed October 26, 2023