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Joseph Spencer
DOS 518 Professional Issues in Medical Dosimetry
ROILS Assignment – Case Review

Medical errors can have serious consequences in healthcare, and radiation therapy is no
exception. In this case, a dosimetrist received a verbal order from a physician to generate a
treatment plan delivering 3600 cGy to a patient. However, the dosimetrist misunderstood the
physician's intent. The physician intended to prescribe 300 cGy per fraction for 12 fractions,
totaling 3600 cGy. Instead, the dosimetrist generated a treatment plan prescribing 180 cGy per
fraction for 20 fractions, still totaling 3600 cGy. This error went unnoticed, and the plan was
approved by the physician and subsequently exported to the treatment unit. It was only after nine
fractions that the physician realized the lack of tumor regression and identified the discrepancy in
the daily dose prescription.
Radiation oncology encounters unique communication hurdles. Precise and clear
communication within the radiation oncology team, especially regarding prescription, is
imperative for safeguarding patient well-being. One significant contributing factor to the before
mentioned error was the miscommunication and lack of clarity in the verbal order. The absence
of a written prescription and the reliance on verbal communication between the physician and
dosimetrist led to a misunderstanding. The physician's intent to prescribe 300 cGy per fraction
was not explicitly communicated, and the dosimetrist interpreted the prescription differently.
This highlights the importance of clear communication in healthcare, especially when dealing
with complex treatment plans.
Another critical factor was the absence of an independent double-check or verification
process. The dosimetrist generated the treatment plan, which was approved by the physician
without a thorough review of the prescription details. An independent double-check of the
treatment plan against the physician's prescription could have identified the discrepancy between
the intended and generated prescription, preventing the error from reaching the patient. A second
set of eyes reviewing the treatment plan is a standard practice in healthcare to catch errors before
they affect patient care.1
To prevent similar errors in the future, healthcare facilities involved in radiation therapy
should establish and strictly enforce a written prescription policy. Physicians should be required
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to provide written prescriptions for all radiation treatments. The American Society for
Therapeutic Radiation Oncology (ASTRO) recommends that prescriptions should be in a
standardized written format, including the patient’s name, treatment site, method of delivery,
prescribed dose per fraction, the total dose, and the number of fractions.2 Standardized
prescriptions enhances precision and clarity in communication, thereby diminishing the
likelihood of interpretation errors. Medical dosimetrists, medical physicists, and radiation
therapists can then use the written prescriptions as a clear reference to ensure that the intended
prescription matches the treatment plan.
A crucial safeguard against dosimetry errors is the implementation of a mandatory
independent double-check process. Examining therapy treatment plans independently is
considered an essential component of the therapy verification process.3 Before a treatment plan is
approved and exported to the treatment unit, a second qualified healthcare professional, such as
another physician, physicist, or dosimetrist, should independently review the prescription and the
generated plan to confirm that they match. Besides a peer review approach, automated detection
tools are in development to detect prescription anomalies.1 These additional layers of verification
can catch discrepancies like the one in this case before they impact patient care. The independent
double-check process should be a non-negotiable standard in radiation therapy departments.
Administering radiation therapy requires a collective effort and transparent
communication among the radiation oncologist, medical physicist, dosimetrist, and radiation
therapist. Miscommunication can have severe consequences for patient safety. The case
discussed illustrates how miscommunication and a lack of independent verification can lead to
dosimetry errors. By implementing a standardized written prescription policy and making
independent double-checks mandatory, healthcare facilities can reduce the risk of such errors and
ensure the safety of patients undergoing radiation therapy. Clear communication and robust
verification processes are essential to delivering high-quality and safe radiation therapy
treatments.
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References

1. Li Q, Wright J, Hales R, Voong R, McNutt T. A digital physician peer to automatically

detect erroneous prescriptions in radiotherapy. NPJ Digit Med. 2022;5(1):158.
https://doi:10.1038/s41746-022-00703-9
2. Evans SB, Fraass BA, Berner P, et al. Standardizing dose prescriptions: An astro white
paper. Pract Radiat Oncol. 2016;6(6). http://doi:10.1016/j.prro.2016.08.007
3. Pennsylvania Patient Safety Authority. Errors in radiation therapy: Advisory.
Pennsylvania Patient Safety Authority. Accessed October 20, 2023.
https://patientsafety.pa.gov/ADVISORIES/Pages/200909_87.aspx.