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Christina Ong

RO-ILS Case Study

September 23, 2018

‘Planner Wrote Prescription for the Physician to Sign’

Radiation Oncology Incident Learning System (RO-ILS), developed and sponsored by

American Society of Radiation Oncology (ASTRO) and American Association of Physicists in
Medicine (AAPM), is a standardized database of problem reporting and incident learning in
radiation oncology. It was launched in 2014 with the mission to “facilitate safer and higher
quality care in radiation oncology by providing a mechanism for shared learning in a secure and
non-punitive environment.”1 For this assignment, a case study logged into RO-ILS is analyzed
for at least two contributing factors that led to the error as well as two actions and/or
recommendations that may prevent the error from reach another patient.

The case study selected for this assignment is when the medical dosimetrist wrote the
prescription for the radiation oncologist to sign, and it is stated as follows:

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.

First and foremost, a prescription for a radiation therapy treatment plan should be written
and entered into the electronic medical record (EMR) by a radiation oncologist, not a medical
dosimetrist. A verbal order for prescription is not substantial enough for it to be documented by a
non-physician and used for treatment. Moreover, the fact that the physician approved the
treatment plan with the incorrect prescription suggests either he/she did not check the
prescription or he/she only confirmed the total dose and not the dose per fraction or the number
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of fractions. This incident indicates there is no formal procedure in place for the dose
prescription process at the facility it happened at.

To prevent this incident from repeating itself, standardizing dose prescriptions and
involving a medical physicist in the approval stage of treatment planning can be helpful. Starting
with the physician writing the dose prescription and submitting it directly to EMR can greatly
reduce the chance of a wrong dose being delivered. The dose prescription is to include: patient
name; date of birth; medical record number (MRN); treatment site; method of delivery; dose per
fraction; total number of fractions; total dose. Unit of cGy is recommended for use in dose
prescriptions as decimal point use that is prone to error is minimized, the likelihood of radiation
overdose is less if cGy is applied compared to Gy, and many other valid reasons which are
discussed in an ASTRO white paper by S.B. Evans et al.2 This initial step completed by the
physician is critical, especially given that radiation therapy has evolved from 180cGy/fraction as
the traditional fractionation to now hypofractionation treatments of 900cGy/fraction being
acceptable, for example. In addition to a dose prescription, a treatment planning directive
containing key components of a treatment plan is essential. The key components are but not
limited to: target dose; fractionation; coverage goals; organs at risk (OAR) goals; plan
parameters (i.e. treatment intent, energy, and treatment modality); image guidance. With a
treatment planning directive, the medical dosimetrist can create and design the proposed
radiation therapy for patients. Moreover, adding the medical physicist in the approval process
prior to start of treatment can be advantageous in finding and correcting mistakes that may have
been missed by the medical dosimetrist and the physician.

This case study from RO-ILS demonstrates how accurate communication is vital in
radiation oncology, whether it is between human-to-human, human-to-machine, or machine-to-
machine. Lack of communication or miscommunication can generate errors and incidents that
could have been otherwise prevented. It is important that the prescription of radiation therapy is
clearly and unambiguously written by the physician to ensure patient safety and delivery of the
desired course of treatment.
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References

1. American Society of Radiation Oncology. Radiation Oncology Incident Learning System.

https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS. Accessed
September 23, 2018.
2. SB Evans, BA Fraass, P Berner, et al. Standardizing dose prescriptions: An ASTRO
white paper. Pract Radiat Oncol. 2016;6(6):e369-e381.
http://dx.doi.org/10.1016/j.prro.2016.08.007