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Jeanette Keil
Professional Issues
ROILS Assignment
September 26, 2018
Case Analysis
The final assignment for this course involved looking into the American Society for
Radiation Oncology’s (ASTRO) Radiation Oncology Incident Learning System (ROILS) to
discuss a case and think about how the reported error was made and the pathway in which the
mistake was caught and reported. In my clinic, we reference the ROILS reports in almost every
meeting and use this as a learning tool whenever possible. It is important to remain vigilant in
our patient’s safety by using these resources, so we can provide outstanding care for our patients
and their loved ones. For this assignment I decided to discuss the first case in which a
dosimetrist wrote a prescription for the physician to sign. The details of this case from the
ROILS quarterly report are:

The physician’s intent was 300 cGy x 12 fractions to 3,600 cGy, but the plan was generated
for 180 cGy x 20 fractions. The planner prepared the formal prescription for physician
approval. The discrepancy was discovered after 9 treatments when the physician saw the
patient on weekly management and did not observe the expected tumor regression. The
physician also noticed that the accumulated dose was not a multiple of 300.1

This is a great example of something that many dosimetrists might see happen in their clinic. There
are several points in this case where a mistake was made and there are some solutions that can be
put into place to ensure this error will not happen again.
While reading this case study I thought of several contributing factors that led to this
mistake and some recommendations to help prevent this error in the future. The first mistake was
that there was a failure in communication between the physician and the dosimetrist regarding the
intended prescription. This can easily happen when giving verbal instructions but should be
confirmed by the dosimetrist when presenting the plan to the physician and while preparing the
plan for treatment by looking at the script again. In this case the dosimetrist prepared the
prescription for the physician so misunderstanding was placed in the patients record and verify
system. The physician did not double check to see if the prescription was correct and hence the
error occurred. My recommendation to make sure that this does not happen again is for the
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physician to be solely responsible for entering all prescriptions. In my clinical setting we rarely
enter a prescription for a physician and is usually done in an emergent case with verification from
the physician. Although this was an error that I think was shared between dosimetrist and
physician, it is the radiation oncologist’s responsibility to be manage the patient’s treatment by
reviewing dosimetry, dose delivery, treatment parameters, patient setup, and portal images.2
The second factor in this case was the failure to double check the accumulated dose once
the patient was under treatment. I am going to assume that this patient did have one prior under
treatment visit with the physician since the mistake was caught on the 9th fraction. This could be
a case of the patient seeing another physician for an under treatment visit or the physician could
have overlooked the prescription again during that visit. I think a great method to again double
check intended dose, treatment intent, and dosimetry plan, is to hold weekly peer review with other
physicians so that any error made can be caught prior to the patient starting treatment. In my clinic,
we hold peer review every Monday and go through all the new patients that will be starting that
week. We look at prescription, dosimetry plans, consults, etc. There have been a few good catches
made during these peer review meetings, but those mistakes did not make it to the patient.
I think that is important to use all the resources that you have in your clinic to put as many
double checks into the treatment planning process as possible. Normally we would rely on the
physicists and radiation therapists to double check documentation and plans for error, but in this
case, I think it would have been unlikely for them to catch this prescription error since the
generated prescription did not look that unusual. Maybe another recommendation would be for
the physicist or radiation therapist to confirm the prescription with the physician as they prepare
the patient for treatment as well.
Many people may see all these safe checks to be a little overkill and tedious. Until someone
is involved in a treatment error and feels the sense of responsibly that huge, they will never
understand the importance of all the safe checks that are put into place. We have a responsibility
to our patients to give them the best we have to offer and that includes making sure they are safe
while in our care.
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References
1. Quarterly Report - Patient Safety Work Product. Chicago, IL: Clarity PSO; 2018:2.
https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Patient_Safety/RO-
ILS/Content_Pieces/2017Q3Report.pdf. Accessed September 26, 2018.
2. American Society for Radiation Oncology. Safety is no accident: A framework for
quality radiation oncology and care. 2012: 1-60.