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Hanaan Habibulla
CQI and Safety ROILS Case Study
October 1, 2020

Continuous Quality Improvements and Safety

Radiation therapy is one of the most common treatments for cancer and cancer symptoms in
approximately 40-60% of cancer patients.2 Although advancements in radiation therapy have
given radiation a bigger role in cancer care, it is also a high-risk procedure because of the many
involvements of procedural steps and staff who all work together to prescribe, plan and deliver
radiation treatment. Errors that occur in radiation oncology could be attributed to human error,
equipment failures and technological errors. In fact, United States Nuclear Regulatory
Commission (US NRC) shows that 60% or more of the radiation therapy misadministration
incidents were related to human errors.3 Continuous quality improvements (CQI) is an ongoing
process established to identify and assess problems and utilizing the obtained assessment to
make improvements.1 Radiation oncology facilities need to implement CQI to achieve and
improve the quality and safety of patient care.
With the involvement of many steps and staff, radiation therapy is extremely susceptible
to error. In 2011, the American Society for Radiation Oncology (ASTRO) conducted a survey
revealing that 85% of radiation oncologists and 94% of medical physicists use a confidential
reporting system for medical errors and near misses.4 Together, ASTRO and American
Association of Physicists in Medicine (AAPM) created Radiation Oncology Incident Learning
System (RO-ILS) as a web-based incident reporting tool. Participants may report cases that may
or may not have caused harm such as misadministration errors, close calls, good catches and near
misses, all without fear of being investigated by malpractice lawyers. The purpose of this system
is to record data and to improve quality and safety throughout the radiation oncology for
participants to voice their work incident to benefit others.5
There was a case from 2017 RO-ILS quarterly report that disclosed a weekend treatment
gone wrong for a patient requiring whole brain radiation. Two therapists and a physician were
present during patient clinical setup. One of the therapists used the wrong scale on the caliper to
measure patient’s head lateral separation. The measurement obtained was 30 cm, which was
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twice the measurement it would have been if done correctly. As a result, the patient ending up
receiving a 28% higher dose than prescribed.5
By analyzing this case, when the therapist took lateral measurement and obtained the
number to be 30 cm, it should have alerted him or her as something abnormal. The average width
of human head is 14 to 16 cm. The reading should have alerted the therapist that the
measurement did not make sense. In article “Negligence, genuine error, and litigation”, Sohn7
reported the importance to differentiate between system error and negligence; he defined system
error as an occasional simple human error, and negligence as an incorrect decision and a failure
to meet standard level of care. In this case, the therapist followed the standard of procedure by
taking a measurement, but unintentionally made mistake. So, this was a system error and was not
considered a negligence. The second mistake was the second therapist and physician failed to
verify the lateral head measurement. Even though this is a simple thing to do, most personnel do
not double-verify due to time restriction or they put their trust on the other person. Another
contributing factor is the possibility that weekend treatment with clinical setup is not commonly
done in that facility. There were also possibilities that the therapists did not have enough
training, preparation or experience in using radiation therapy instruments, as well as a lack in
performing hand calculations.
Based on this incident, there is a need to be a dosimetrist or a physicist on an on-call
rotation. This is necessary to ensure the safety and accuracy of treatment planning delivery on
weekends or at hours when treatments are not normally performed. In addition, the presence of
dosimetrist or physicist is necessary in order to integrate safety into a standard treatment
planning process. It is critical that every treatment plan is verified for its accuracy. Another
consideration that would prevent such incident is to standardize dosimetry instruments within the
department. Unnecessary additional instruments that are not used should be kept in the storage.
The physics department can provide just one type of caliper for use to measure any patient
anatomy, usually in centimeter margins, to prevent any future errors. Any staff who may
potentially use this caliper in the future should undergo routine training to prevent future errors.
“Learn culture” should be recognized and applied in all healthcare facilities as a means of
preventing future occurrences3. Making errors is a fact of life that cannot be eliminated but
certainly its frequency can be reduced. This is the ideology that RO-ILS was built on, a means to
report mistakes and serve as an educational opportunity for all.
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As with any healthcare facility, all team members must work together to create a safe and
efficient working environment without sacrificing quality of work. Understaffed, unreasonable
workloads, and improper training may lead to treatment errors. Double verification of patient
information such as correct name, body part, laterality, and prescription need to be emphasized.
The entire department needs to acknowledge all of the incidents that occur based on a fact
without speculation or trying to blame one singular person. Whether they are critical injuries,
minor injuries or near-misses, every personnel member has a responsibility to take necessary
corrective measures and learn from those mistakes to prevent incidents in the future.3

References:
1. Continuous quality improvements. National Commission on Correctional Health Care
Website. https://www.ncchc.org/spotlight-on-the-standards-24-1. Accessed October 1,
2020.
2. Errors in radiation therapy. Pennsylvania Patient Safety Advisory. 2009;6(3):87-92.
Patientsafety.pa.gov/ADVISORIES/documents/200909_87.pdf. Accessed October 1,
2020.
3. Ganesh T. Incident reporting and learning in radiation oncology: Need of the hour. J Med
Phys. 2014;39(4):203-205. http://dx.doi.org/doi:10.4103/0971-6203.144481. Accessed
October 1, 2020.
4. Newitt VN. Error reporting in radiation oncology. Radiology Life Website.
http://radiologylife.advanceweb.com/error-reporting-in-radiation-oncology/. Accessed
October 1, 2020.
5. Radiation oncology incident learning system (RO-ILS). ASTRO website.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS. Accessed
October 1, 2020.