Christopher Maurino

DOS 518 – Professional Issues in Medical Dosimetry

RO-ILS: Patient Safety Case Study

Prompt: Case one: Planner wrote prescription for the physician to sign.

The 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.

After reading the four case studies provided to us, it made me realize how many

mistakes can be made during patient treatment delivery. It is our responsibility in radiation

oncology to minimize as many avoidable mistakes as possible. To allow each department to

learn from the mistakes of others and to make radiation oncology as safe as possible, the

American Society for Radiation Oncology partnered with the American Association of Physicists

in Medicine to established a national radiation oncology-specific incident learning system,

Radiation Oncology Incident Learning System (RO-ILS). 1 The RO-ILS program was launched on

June 19, 2014 and was designed to assist in capturing information that would help improve the

quality of care and safety of patients in the future through shared learning. 1
 An example of how the RO-ILS program has lead to the improvement of a radiation

oncology department was documented by Nelson et al.2 They explained that “near miss” events

had reduced from 78% to 9% prior to April 2014 to May 2019 and that there had been a major

focus on “process improvement” within their department. 2 The example provided from our

prompt could be labeled as a process improvement event. The process in this situation was a

verbal order of a prescription by the doctor to the dosimetrist. Verbal requests can be

unreliable and lead to errors, which hopefully, do not reach the patient. Unfortunately, this

error had reached the patient and was caught when the physician expected to see more tumor

regression, only to discover the patient was only receiving 180 cGy per fraction. The error could

have been prevented by a few process improvements. A written planning directive should have

been created by the physician and reviewed by the dosimetrist prior to treatment planning.

Had this been done, the doctor would have directly written that they wanted 12 fractions

instead of 20, thus being completely clear on the prescription. With this information, the

dosimetrist could have validated their assumptions or found that they had assumed an error. If

a written planning directive was in place, a physicist or secondary person that check the created

plan prior to treatment could have spotted the error had the written directive and created plan

been different. Another contributing factor that led to the error was that the physician was not

the person responsible for entering the prescription, and then assumed that the prescription

was properly filled out. The physician should be responsible for manually confirming ever

element of the prescription prior to plan approval. Had the physician not made assumptions

about the correct fractionation, they could have realized that a mistake had been made and

had the dosimetrist re-planned the case.

 Quality of care and safety of patients should be the number one priorities of a radiation

oncology department. When errors arise, they can have devastating effects. The error in this

scenario was thankfully not fatal, however, the treatment to the patient was not adequate.

Through shared learning, other institutions could learn from this error and errors similar to this

in order to hopefully make adjustments to their own department’s workflow to avoid similar

errors. With more errors being identified through RO-ILS, more errors can be avoided, making

more radiation oncology departments safer places for patients to be treated.

 References

1. RO-ILS Background - American Society for Radiation Oncology (ASTRO) - American

Society for Radiation Oncology (ASTRO). ASTRO. https://www.astro.org/Patient-Care-

and-Research/Patient-Safety/RO-ILS/RO-ILS-Background. Accessed October 5, 2020.

2. Nelson, C. Roy, LA. Wallace, HJ. Radiation Oncology Incident Learning System (RO-ILS):

Increasing stakeholder participation for safety and quality improvement. Am J Clin

Oncol. 2019;37(27_suppl):232. Doi:https:// 10.1200/JCO.2019.37.27_suppl.232. Pub

September 20, 2019.