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Lisa Spanovich

The Medical Dosimetrists Role in Safety

Due: October, 8, 2017

The role of the Medical Dosimetrist is always evolving. As technology, and processes
change, and so does the way we treat our patients. Even though the world of radiation therapy
has made many monumental advances over the years, some can argue that it has made the
workers have to think less. Now with the heavy reliance on computers, there are so many more
ways that mistakes can occur in radiation therapy. Safety has been a topic of interest due to
recent tragedies involving patients radiation treatments. In a New York Times article, Scott
Jerome-Parks received radiation treatments for his head and neck cancer, but because of a
computer error, the treatment machine gave an enormous amount of radiation to his brain stem
and neck.1 He soon after passed away from radiation overdose.1 The new era of dosimetry needs
to pay extra close attention to the safety of our patients. Some ways that Medical Dosimetrists
can integrate safety into their daily practice is to make sure there is clear communication, to
make sure that they are diligent in their actions, and to make sure that an adequate quality control
process is in place.

Clear communication is an important aspect in every part of our lives. The role of the
Medical Dosimetrist is to develop a plan based off of many factors such as the patients state of
health and what the physicians preferences are. The physician consults the patient, and at that
time, the patients state of health and previous health issues are determined. A plan must be
based off of the ability for the patient to hold still for the length of their treatment.
Communication must be open so that critical information can be acknowledged by the radiation
oncology team.

An example of a possible lack of communication is if a patient has a pacemaker and that

information does not get passed on to the necessary staff members. Some pacemakers might not
behave appropriately if it receives over the recommended radiation dose, per the manufacturers
specifications. A possible scenario would be if a patient did have a pacemaker, and we are
planning to treat the patients abdomen. When the radiation therapist simulates the patient, and
the radiation therapist does not scan superior enough to notice the patient has a pacemaker. The
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scan is then sent to dosimetry for planning. The plan is completed, the patient has xrays taken to
verify isocenter, and the patient is subsequently treated with radiation. Situations similar to this
have happened within radiation oncology departments. It is imperative to inform all staff of
important information such as a patient having a pacemaker, so that the departments pacemaker
protocol can be accurately followed. It must be made a priority to relay this information to the
necessary staff.

Some ways to avoid situations like this is to make a conscience effort to alert all staff that
needs to be aware of a patient who as a pacemaker. Instead of verbal communication, a facility
may choose to add a task to the patients assessment/checklist, so that multiple staff members
must check off whether or not the patient has a pacemaker. There may be an instance where the
staff member isnt sure if the patient has a pacemaker. If this is the case, the staff member is to
check the patients chart for verification. Utilizing this method makes each staff member
responsible for making sure they check if the patient has a pacemaker. No one can claim that
there were never notified, and push blame to others.

Communication is crucial for all aspects of radiation oncology. Physicians and Medical
Dosimetrists work together for many years, theres an understanding of the type of plans the
Physician would deem acceptable. One or more treatment plans are presented to the physician,
who ultimately decides to accept or reject the plan.2 It is necessary for the Medical Dosimetrist to
make the physician aware of any possible drawbacks within the plan, such as a hot spot being in
an undesirable location or if dose constraints are close for a certain structure. Also, if the patient
had previous radiation treatment, it is imperative that the dosimetrist is aware of it and plans
accordingly, with the hopes that the patients previous treatment plan can be fused to the
patients current scan.

Another way that Medical Dosimetrists can integrate safety into their daily work is to
make sure that they are not just going through the motions. Medical dosimetry is unique in the
way that every plan that is developed is custom to that patient, depending on the extent of
disease, internal anatomy, and patient positioning. But almost everything outside of treatment
planning is very repetitive. Some might say it is easy to get complacent when doing things such
as filling out the patients assessments/checklists or processing the plan. Dosimetrists do get
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comfortable to knowing what the checklists ask, but it is important to make sure that you are
checking each item listed on that checklist.

Complacency goes beyond filling out a patients checklist for treatment. One example
would be if a patients positioning differs from the typical patient positioning. The majority of
patients that receive radiation are treated will be in the supine position. When a patient does get
treated in the prone position, as Medical Dosimetrists, we need to make sure that we are labeling
the fields appropriately, and most importantly, we need to make sure that the positioning of the
patient is correct in the treatment planning software (TPS). When the radiation therapist
simulates the patient, the anatomical position of the patient must be selected on the CT scanner
so that the computer knows if the patient is supine or prone and head first or feet first. The option
that is chosen for this scan makes the scan get sent in that orientation to the dosimetrist. The
dosimetrist must take notice that the orientation figure in the TPS is oriented in the same way as
the scan. It is common for the radiation therapist to forget to change the orientation when
scanning the patient, but it is ultimately the dosimetrists responsibility to correct it.

Another way to integrate safety into our profession to keep an honest Quality Control
Trigger (QCT) list. Quality control triggers are a way to keep track of situations that occur within
the department. This is done to keep everything out in the open about situations such as reasons
for breaks in the normal work flow, whether it delays a patients treatment or not. Some
examples of a QCT would be if a physician was paged to a treatment machine to view a setup,
and he/she never shows up, or if someone filled out a simulation form with incorrect
information. The information that is collected involves instances where the normal flow of the
workday was interrupted or delayed due to an issue. Because most radiation oncology
departments should run like a well-oiled machine, we need to know if there are bumps within the
flow of the department, and we can then focus on finding a solution to fix the bumps.

W.E. Deming pushed the philosophy that one should treat manufacturing as a system,
rather than bits and pieces. This concept transfers to the flow of a radiation oncology
department, because the department must be looked at as a whole system for how it is
functioning, not just one part of the group. We strive for this because most problems are found in
the processes, not in the people. Continuous quality improvement (CQI) does not seek to blame,
but rather to improve processes.3 If there are issues in medical dosimetry where the plans are not
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getting developed as quickly as needed, we must figure out where the problem lies. Some
possible issues could be if the physician is waiting until the last minute to draw volumes, or if the
Medical Dosimetrist is not prioritizing his/her schedule.

Technological advances within radiation oncology help to deliver better and more
accurate radiation treatments. We need to welcome this technology, but welcome it with an
understanding that there are more ways to harm our patients with this technology. Dr. Howard I
Amols, chief of clinical physics at Memorial Sloan-Kettering Cancer Center in New York said,
Linear accelerators and treatment planning are enormously more complex than 20 years ago.
He went on to further explain that hospitals are too trusting of the new computer systems and
software.1 It is never okay to just assume the computer or software is correct. Its never okay to
assume anything in regards to your job; thats when mistakes happen. If the radiation oncology
staff has good communication, are alerted while performing tasks, and if a continuous collection
of department flow issues are found and subsequently fixed, it can make an enormous difference
in regards to keeping our patients safe.
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References

1. Bogdanich W. Radiation offers new cures, and ways to do harm. NY Times Website.
http://www.nytimes.com/2010/01/24/health/24radiation.html?mcubz=0. January 23,
2010. Accessed October 5, 2017.
2. Blumberg AL, Burns RA, Cagle SW, et al. Safety is no accident: a framework for quality
radiation oncology and care. [PDF]. ASTRO website.
https://www.astro.org/uploadedFiles/Main_Site/Clinical_Practice/Patient_Safety/Blue_B
ook/SafetyisnoAccident.pdf. Accessed October 6, 2017.
3. Lenards N. Operational Issues in Radiation Oncology: Continuous Quality Improvement.
[SoftChalk]. La Crosse, WI: UW-L Medical Dosimetry Program; 2016.