Roils Case Study-3 1

Alicia Wilson
DOS 518
ROILS Case Study
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.
This treatment error was recorded as part of the Radiation Oncology Incident Learning
System (ROILS). The ROILS system was designed as a way to review and analyze mistakes and
near misses as a method to improve quality, reduce error, and improve patient outcomes. When
reviewing cases like this, it is important to pick out what could have led to the error; and what
actions can be put in place to prevent the mistake from happening again. The more we become
aware of what leads to errors, the better we can prevent them in the future.
The first contributing factor that stood out to me was that the dosimetrist was asked to
take a verbal order and enter it into the electronic medical record. This seems to be a policy
violation in two ways. First, according to the American Association of Medical Dosimetrists’
(AAMD) scope of practice of a medical dosimetrist1, the medical dosimetrist is responsible for
the “generation of isodose distributions, and performance of dose calculations according to the
radiation oncologist’s written directive/orders.” It is outside of their scope of practice for a
medical dosimetrist to write the prescription. While it could be argued that they were dictating a
verbal order, the case then argues whether verbal orders are appropriate.
In order for a facility to participate in using verbal orders, they should have an
organizational policy on the subject. According to the National Coordinating Council for
Medication Error Reporting and Prevention (NCCMERP)2, verbal orders should be authorized
by an organization’s policy. This policy must specify who is authorized to receive a verbal order.
They also recommend that the authorized individual taking the order read it back to the provider.
There is no evidence in this incident report that the dosimetrist read the prescription back to the
radiation oncologist at the time. The NCCMERP also recommends that the authorized prescriber
reviews and signs the prescription at a later date to validate its accuracy. The American College
of Radiology (ACR) states that the Radiation Oncologist is responsible for the radiation
prescription including the target volume, treatment technique, beam modifying devices, radiation
modality, beam energy, dose per fraction, number of fractions, fractionation schedule, total dose,
prescription point/isodose line, and imaging.3 The ACR dictates that the radiation prescription
and plan must be signed and dated by the radiation oncologist prior to the initiation of treatment.
This incident report states that the physician signed the plan, but does not specify that the
physician signed the prescription prior to the patient initiating treatment. Due to the high risk of
errors resulting from verbal orders and the ease of electronic medical record use, the NCCMERP
recommends that verbal orders be used infrequently and for cases such as on-call or emergency
care, where the use of written electronic prescriptions and orders may be problematic.2
The second causative factor that I saw in this case was that it was not mentioned whether
the case was presented for peer review in the form of chart rounds. According to the ACR, part
of the quality improvement program required for accredited facilities is peer review.3 This peer
review can be in the form of a chart rounds meeting. The ACR is very specific in the required
components of a peer review meeting. The physicians should present all new and recently started
radiation patients to an audience including the department’s physicists, dosimetrists, radiation
therapists, and nursing staff. The discussion should include indications for treatment, targets,
dose per fraction, total dose, fractionation schedule, and dose-volume histogram. If this patient
were presented in a peer review meeting in such a way, this prescription error should have been
caught prior to the patient starting treatment.
My first recommendation in response to this case would be to eliminate the use of verbal
orders. The radiation oncology department is not an emergency department. While physicians
may be busy and short on time, they are rarely in circumstances that would be considered
emergency situations. Even in an on-call situation, the physician would be a member of the
facility and familiar with the electronic charting system. Eliminating verbal orders cuts down on
the miscommunication and misunderstanding of information that can lead to prescription errors.
My second recommendation in response to this case would be to either initiate a peer

review if there is not one currently, or update their existing peer review meeting to include a
review of the prescription including fraction dose, number of fractions, and total dose.
Sometimes when things become routine, we become lax on some of the specifics. It would be
beneficial to have a leader for the peer review who was responsible for keeping the meeting on
track and ensuring that all of the appropriate material is covered. Having someone in charge who
is organized, vocal, and a strong leader would help ensure that the format of the peer review
covers the appropriate topics.
Awareness and accountability are the most important factors for acknowledging errors
and preventing them in the future. If we view incident learning as a tool to improve safety and
quality rather than a method of placing blame, we will indeed improve our industry. Often
people are afraid to report errors, for fear of retaliation, so it is imperative to erase that stigma
and shift the focus from condemnation to education. One of the most successful and permanent
ways to learn is to admit mistakes and look for ways to change the future.
References
1. American Association of Medical Dosimetrists. AAMD Scope of Practice Task Group.
Scope of practice of a medical dosimetrist. May 28, 2019.
https://pubs.medicaldosimetry.org/pub/0960C266-988C-CF53-6428-690598E7E617 .
Accessed September 12, 2020.
2. National Coordinating Council for Medication Error Reporting and Prevention.

Recommendation to reduce medication errors associated with verbal medication orders
and prescriptions. May 1, 2015. https://www.nccmerp.org/recommendations-reduce-
medication-errors-associated-verbal-medication-orders-and-prescriptions#:~:text=Verbal
%20orders%20are%20those%20orders,with%20law%20and%20regulation2. Accessed
September 12, 2020.
3. American College of Radiology. ACR-ASTRO practice parameters for radiation

oncology. 2018. https://www.acr.org/-/media/ACR/Files/Practice-
Parameters/RadOnc.pdf. Accessed September 12, 2020.

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Alicia Wilson

Case one: Planner wrote prescription for the physician to sign

My second recommendation in response to this case would be to either initiate a peer

2. National Coordinating Council for Medication Error Reporting and Prevention.

3. American College of Radiology. ACR-ASTRO practice parameters for radiation

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