Dos 518 Roils

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Spencer Day
DOS 518
ROILS: Case 1
In this case study where the medical dosimetrist created the prescription, a misassignment
of responsibilities, lack of redundancy, and poor communication led to an adverse event. The
situation begins with the physician intending to dose a malignant neoplasm to a total dose of
3600 centi-Gray (cGy). The physician’s intention was to deliver the prescribed dose in 300 cGy
increments, dividing the total dose into 12 fractions. The medical dosimetrist was then verbally
instructed by the physician to plan the treatment for 3600 cGy, without elaborating on the
fractionation scheme. A fractionation of 180 cGy/fraction for 20 fractions was then entered by
the medical dosimetrist into the electronic medical record (EMR) and attached to the plan. The
treatment plan was then reviewed and approved by the physician as well as the physicist.
Radiation was administered to the patient under the incorrect prescription for 9 fractions. During
weekly checkup on the second week of treatment, the physician noticed a lack of tumor response
and checked the EMR to discover the medical dosimetrist had input the incorrect fractionation
scheme.
Within this case, there are three errors that manifested into an incorrect prescription being
treated. The first error is responsibility being delegated to the wrong person. Secondly, a lack of
communication exacerbated the error. Finally, redundancy in double checks by the physicist and
radiation therapists failed to catch the error.
The radiation oncologist is responsible for creating the prescription that includes total
dose and fractionation that the medical dosimetrist will then follow. While the medical
dosimetrist may create the prescription for treatment, it is up to the physician to approve this
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prescription. The prescription must be approved by the physician before treatment, and great
scrutiny should be given to the prescription by the physician, especially in the case where they
did not create it. The dosimetrist should also be aware that it is their responsibility to alert the
physician to double check their prescription.
Communication is a vital factor for all radiation oncology departments to master.
Considering the contributing factors of radiation oncology events, communication accounts for
20% of these events. Examining communication errors demonstrates three similarities with this
case study. Poor or incomplete information composes 34% of communication errors, which is
present in this case. Failure to request needed information, 7% of communication errors, is
exemplified by the dosimetrist not seeking clarity on the prescription. Finally, an inadequate
communication pattern (23% of communication errors) is illustrated by delegating prescription
creation to the medical dosimetrist verbally with little clarity and no written double check.1 The
physician knows the radiobiological impact of differing fractionation schemes and should not
have assumed the medical dosimetrist would input the correct prescription without giving
fractionation. Additionally, the medical dosimetrist should have recognized the importance of
fractionation schemes as well and asked the doctor for clarification.
The medical field and especially radiation oncology is structured with numerous
redundancies and oversite built into the workflow. The American College of Radiology
recommends a radiation treatment plan be reviewed by the physician and approved within a
week.2 Other radiation oncology workers review the treatment plan to confirm perfection as well.
After physician approval, the physics department will scrutinize the plan. Radiation therapists
also observe the plan before beaming on. Interestingly, most of the documented errors were
caught by radiation therapists.1 While unknown, many of the undocumented errors were probably
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caught by dosimetry, a physician, or the physicist. However, this statistic illustrates that every
worker who interacts with the radiation treatment plan has the responsibility to review it.
Mistakes can be caught at all levels.
Several solutions incorporating all roles can be implemented to avoid adverse events.
Communication cannot be undervalued. From the viewpoint of the doctor, they should never
assume fractionation is implied. To ensure the clarity, the physician should input the prescription
themselves. While prescription creation should remain the physician’s responsibility, if the
medical dosimetrist is to input the prescription, the radiation oncologist should provide a written
note, with all details of the prescription included. Focusing on the medical dosimetrist, any task
that is delegated to them that is normally the doctor’s responsibility should be double-checked by
the physician before continuing with treatment planning. This includes not only the prescription,
but also physician contours (GTV, ITV, PTV, et cetera). Lastly, all workers that interact with the
treatment plan should thoroughly review the plan and employ a checklist. Checklists provide
consistency as to the parameters that are checked and can be improved as necessary.
Roughly 50% of adverse radiation treatment events occur at the treatment planning level.3
As evidenced in this case study, poor communication results in misinterpretations and
consequently an adverse event. Additionally, it is the responsibility of all radiation oncology
workers to examine a new plan. No assumptions should be made that the previous reviewer
caught all the mistakes. Redundancy, double checks, and communication are critical for radiation
oncology remaining a safe, effective therapy.

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References
1. Radiation Oncology Incident Learning System. Aggregate report: Q1-Q2 2018. Published
2018. Accessed October 6, 2021. https://www.astro.org/ASTRO/media/ASTRO/Patient
%20Care%20and%20Research/PDFs/ROILS-Q1-Q2_2018_Report.pdf
2. Pennsylvania Patient Safety Authority. Errors in radiation therapy. Pennsylvania Patient
Safety Advisory. 2009;6(9):87-92.
https://collections.nlm.nih.gov/master/borndig/101561978/Errors%20in%20radiation
%20therapy.pdf#:~:text=The%20most%20common%20errors%20reported,the%20wrong
%20patient%20being%20treated
3. Foster, R. SRS/SBRT Errors and Causes. Presented as part of AAMD Spring 2019
Regional Meeting. April 6, 2019. Charlotte, NC.

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1

radiation therapists failed to catch the error.

physician to double check their prescription.

Communication is a vital factor for all radiation oncology departments to master.

present in this case. Failure to request needed information, 7% of communication errors, is

communication pattern (23% of communication errors) is illustrated by delegating prescription

fractionation schemes as well and asked the doctor for clarification.

Mistakes can be caught at all levels.

As evidenced in this case study, poor communication results in misinterpretations and

consequently an adverse event. Additionally, it is the responsibility of all radiation oncology

oncology remaining a safe, effective therapy.

2018. Accessed October 6, 2021. https://www.astro.org/ASTRO/media/ASTRO/Patient

2. Pennsylvania Patient Safety Authority. Errors in radiation therapy. Pennsylvania Patient

Safety Advisory. 2009;6(9):87-92.

Regional Meeting. April 6, 2019. Charlotte, NC.

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