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Michael S Wheatley
DOS-518 Professional Issues in Medical Dosimetry
ROILS Case Study

Introduction:
In 2005 the Patient Safety and Quality Improvement Act (PSQIA) was created to form Patient
Safety Organizations (PSOs). The purpose of these PSOs were to provide healthcare
professionals a place to report and analyze patient safety issues in a confidential and privileged
environment.1 In 2011, through the partnership of the American Association of Physicists in
Medicine (AAPM) and the American Society for Radiation Oncology (ASTRO) the Radiation
Oncology-Specific Incident Learning System (ROILS) was created.1 This was the only incident
learning system specifically for radiation oncology that was sponsored by professional societies.
The ROILS platform provided for a place for participating entities to log radiation treatment
related errors. By having a partnership of institutions committed to enhanced patient safety and a
national database of information, these institutions were able to learn from mistakes to better
promote improved patient safety.
With the use of increased complex technology in Radiation Oncology, the potential for treatment
errors has increased as well. In recent years several of these treatment errors have been reported
in the media making it even more important to increase our safety measures to prevent similar
errors from occurring. In a series of reports in the New York Times, treatment errors were
highlighted to include the lack of patient safety concerns.2 These reports cast radiation
treatments in a negative light creating fear in the general public.
As a result of several of these high-profile treatment errors resulting in deaths, patient safety was
made a top priority. By using incident learning systems such as the ROILS database, it provides
healthcare organizations a place to report these errors in a non-judgmental way to promote
learning from these mistakes. It is important to note that organizations must still report treatment
errors through proper reporting entities as required by state and national standards.
Case Study:
A treatment error case was submitted to ROILS which involved an emergency on call treatment
over a weekend. The only staff present were the Radiation Oncologist and two Radiation
Therapists. The patient required whole brain external beam radiation therapy involving an in-
treatment room clinical setup. During the clinical setup the separation was taken by one of the
Radiation Therapists and the value was incorrectly read from the caliper resulting in an incorrect
Monitor Unit calculation. Over the course of two fractions the patient received a 28% overdose
as the error was not discovered until before fraction 3 was delivered at the time a formal plan
was completed by the Medical Dosimetrist.
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Contributing factors:
So, what went wrong?
In evaluating this error, I believe that a few simple steps could have been taken to prevent this
mistake from occurring. First the separation measurement should have been taken by the first
Radiation Therapist and then verified by a second measurement performed by the second
Radiation Therapist providing a consensus agreement of the correct measurement. Secondly, the
SSD should have been verified on the patient’s skin to be within reason of the calculated SSD
derived from the separation measurement. For instance, with the separation of 30 cm, while
setting the isocenter to midline one would expect an SSD of around 85 cm for each of the lateral
fields. With this SSD verification it could have been discovered that the skin SSD reading would
not have been within reason to the calculated SSD.
Recommendations:
While on call treatments are routine, not every member of the treatment team may be as
competent in clinical setups resulting in errors not being caught right away. Compounding this
issue is the fact that emergency treatments are performed with limited staff on hand making the
standard policies and procedures in place for end to end treatment plan checks not available.
My recommendations for this situation would be to provide periodic training for emergency on
call procedures involving all on call staff. This training could focus on the need for second
checks and standard procedures for clinical setups such as verifying treatment parameters prior
to delivery of treatment. I would also include proper use of the caliper during the training to
ensure that everyone knows how to properly record an accurate measurement. My feeling is that
additional training will provide a refresher to staff so that when the emergency treatment occurs,
they will be better prepared to carry out the correct procedures.
While it is unrealistic to prevent zero errors from occurring, as healthcare professionals it is our
priority to try and prevent any potential errors while providing the safest care for our patients as
possible. Continued education and training for the treatment team can only help to achieve lower
incidents in errors occurring.
References
1. American Society for Radiation Oncology website. Accessed September 28, 2020.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS/RO-ILS-Background
2. Bolan C. Doubt cast over radiation safety. Imaging Technology News website. March 31,
2010. Accessed September 28, 2020. https://www.itnonline.com/article/doubt-cast-over-
radiation-safety.