Stacey Song

DOS 518 Professional Issues

October 19, 2023

Safety within the medical field is particularly important when dealing with patients

because any mistakes made by attending professionals can have a direct impact on the welfare of

their patients. As a result, there have been systems created such as the RO-ILS: Radiation

Oncology Incident Learning System1 (sponsored by ASTRO, AAPM, Varian, ASRT, AAMD

and Sun Nuclear Corporation,) which are free and which help enforce best practices when

administering treatment to medical patients. Considering such freely available systems, common

mistakes that may occur within a treatment center become more preventable because such a

system provides a baseline of best practices. Because RO-ILS allows professionals to freely

submit case studies without danger of punitive damage 1,3, it can provide cases that can be used

to teach and reinforce best practices within medical staff.

For example, consider the following case: A Dosimetrist took a verbal order to generate a

plan to 3600 cGy and entered the prescription into the electronic medical record. The physician's

intended prescription was 300 cGy x 12 fractions = 3600 cGy but the plan was generated for 180

cGy x 20 fractions = 3600 cGy. The plan was approved by the physician and exported to the

treatment unit. During the second week of radiation therapy the physician saw the patient in the

clinic after the 9th fraction was given to the patient. The physician was surprised by the lack of

tumor regression. Upon checking the electronic medical record the physician noted that the daily

dose was not in multiples of 300 cGy.

 From this case study the medical professionals are introduced to a real-world situation

and challenged to think about the problems that lead up to situation. Some of the more obvious

problems can be determined through thoughtful discussion within all members of the staff,

developing a baseline of understanding of professional processes, responsibilities and

considerations when dealing with prescriptions. From such discussion an examination of RO-ILS

best practices can be used to acquaint the staff of the best course of action. For example, RO-ILS

provides a published case study that examines such a situation, RO-ILS Case Study 16:

Prescription Transcription Error and Incorrect Mus3. In it we can see that when taking down

prescriptions, a few errors were made:

First, that the process of communicating prescriptions should always be in written form.

The responsibility of communicating this information is the physician’s responsibility and

therefore his/her mistake for not writing clearly what needed to be done.

Secondly, the dosimetrist made a mistake of not becoming more acquainted with

reasonable doses that need to be applied and maintaining more vigilance in checking the

prescription. The dosimetrist may not be the physician, but he/she still needs to be aware of the

ranges of what might be deemed reasonable treatment prescriptions to catch possible errors. It

should be the dosimetrist’s responsibility to always consider the prescription’s validity and to not

blindly take it at face value. The fact that the dosimetrist did not do this shows a lack of in-depth

knowledge, a lack of vigilance in verifying the reasonable levels being prescribed, and a lack of

investment in acquainting him/herself with reasonable treatment ranges.

In RO-ILS Case 16, the best practice is that “dosimetrists must review calculated MUs

against a reasonable expectation of calculation result.”3 This was clearly not the case in our
example. However, from this examination of the problem a new process can be created to better

help the medical staff to not repeat the same problem to another patient.

Third, the physician made a mistake of assuming that the prescription was fine, which

also demonstrates a lack of attention to detail. Since radiation oncology is such an exacting

medical service, such disregard for detail is a serious mistake the physician needs to avoid. The

fact that this physician did make such a mistake shows that he/she was acting irresponsibly about

the treatment process.

In RO-ILS’ Case 16, “Lessons Learned and Mitigation Strategies,” Physicians plan

approval “should be standardized; for instance, according to the CB-CHOP format which

stipulates a review of the prescribed dose,” plans should be reviewed in “absolute dose.” 3 In

comparison with the RO-ILS recommendation, the error and potential solution for our example

become more apparent: the amount of information and the format of that information needs to

follow a standard in order to avoid errors. These can be communicated to the staff to better

understand the professional expectations of the staff and the quality of the data being submitted.

When considering these issues, the question of remedy arises: How does a medical

facility avoid these problems? Here are a few ideas that might help:

1. The medical staff should maintain an on-boarding/training program, where new

and existing staff are trained on best practices that RO-ILS provides. Since RO-ILS

provides best practices, its case studies can serve as a good forum for discussing the

expectation levels between the medical staff. All staff members should attend since

seniority in the staff has no bearing on the actual administration of treatment.

2. The medical staff should perform weekly / bi-weekly / monthly / regular follow-

up to discuss new findings, new RO-ILS case studies 1, and to discuss the possible

problems and steps to avoid future issues.

3. Taking from a page of the RO-ILS Case Study 16, a process should be in place

where only physicians are allowed to write prescriptions. This is in accordance with

ASTRO’s 2017 Q3 report2, “The ACR-ASTRO Parameter for Radiation Oncology

and ASTRO’s Accreditation Program for Excellence (APEx®) states that the

radiation oncologist prescribes the radiation treatment course and the dosing pattern.

These directives are in no other radiation oncology team members’ scope of practice,

including the medical dosimetrist nor physicist.”

If this means an online form, then the physician will be required to fill out the

information fully so that there is no room for mistakes. As stated within RO-ILS

Case Study 16, “The radiation oncology community should use the standardized

prescription format uniformly.” Such white papers as that provided by ASTRO 4 may

be of use to provide a starting point for such formats.

4. The facility should consider enforcing a culture of continuous improvement.

Nobody is perfect but maintaining a mission statement where all staff agree to

continuously improve on their own understanding and to cross pollinate it with other

staff will keep the facility constantly moving towards the ideal of being an “100%

safe” environment where patients can be treated with the best results.
 By doing the following and being vigilant when dealing with medical procedures it may

become easier to enforce and continuously improve the staff, medical facility, and the radiation

oncology community.
 References

1. Radiation oncology incident learning system (RO-ILS). AAMD website.

https://www.medicaldosimetry.org/resources/quality-and-safety/
2. Quarterly Report Patient Safety Work Product. Q 2017. ASTRO website.
https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/
PDFs/ROILS-Q3_2017_Report.pdf
3. Prescription Transcription Error and Incorrect MUs. AAMD website.
https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/
PDFs/ROILS_Case16.pdf
4. Evans SB, Fraass BA, Berner P, et al. Standardizing dose prescriptions: An ASTRO
white paper. Pract Radiat Oncol. 2016;6(6):e369-e381.
http://doi.org/10.1016/j.prro.2016.08.007