Adam Schwartz

Professional Issues
September 30, 2018
ROILS- Radiation Oncology Incident Learning System

The physician’s intent was 300 cGy x 12 fractions to 3,600 cGy, but the plan was generated for
180 cGy x 20 fractions. The planner prepared the formal prescription for physician approval.
The discrepancy was discovered after 9 treatments when the physician saw the patient on weekly
management and did not observe the expected tumor regression. The physician also noticed that
the accumulated dose was not a multiple of 300.
Although accidents do occur, there is no excuse for those that could have been prevented

using a retrospective approach built from analyzing past mistakes. A radiation oncology

department makes use of systems and equipment that when implemented correctly, are very

efficient in treating cancer patients. This same equipment and the systems designed to operate

them can also be very complicated and can present serious danger to patients and staff if

mistakes are made. In order to continuously improve the therapeutic capacity of a radiation

oncology department, an organization called RO-ILS (Radiation Oncology Incident Learning

System) was developed with a mission to facilitate safer and higher quality care by providing a

mechanism for shared learning in a secure and non-punitive environment.1 This organization is

sponsored by AAPM and ASTRO and compiles mistakes from participating departments,

sharing the improvements with other departments to collectively improve the field of radiation

oncology. The case above was sent to RO-ILS for review and the findings and improvements are

discussed throughout this essay.

A functioning radiation oncology department necessitates clear, timely, and well

document communication between the medical dosimetrist, therapists, physicists, and

physicians. Lack of a clear communication standard for prescriptions can lead to terrible

mistakes that put the patient’s treatment outcome and overall well being at risk. In the scenario
being discussed, the planner developed a radiation treatment plan that was not only different than

the physician’s intent, but also impossible to correct because of the different daily dose. The

patient was unfortunately treated with 9 fractions using a plan that under-dosed the disease site.

This mistake was facilitated by lack of communication but also occurred as a result of poor

checks from the physician and physicist when the plan was in the approval phase. The

departments systems that are intended to prevent simple errors such as these did not do justice by

the patient and were too loose to catch the mistake. Finally, the department should have caught

the discrepancies at weekly chart rounds where physicians meet and discuss the plans under

treatment. The physician and dosimetrist clearly did not discuss the case in real detail and they

failed to properly review the case until 9 fractions had already been delivered.

In order to prevent such lapses in patient care quality, systems must be well thought-out

and created with every possible scenario in mind. Departments must work towards standardizing

the process of creating a prescription and correctly documenting it electronically or in written

format prior to the start of planning.2 It is essential that the physician correctly expresses their

intent to the dosimetrist so that the planning process can be directed and purposeful. The

physician must also be the only member of the radiation oncology team who determines the dose

and fractionation pattern, not allowing any other member of the team to manipulate this intent.3

This point is important because developing a prescription is technically out of the scope of all

other staff members who are not trained in the same manner as a physician. In regards to the

mistake slipping through the departments pre-treatment checks, a checklist that requires a

prescription check might be of use as it would remind the physicist, dosimetrist, and physician to

double check every aspect of the plan before it can be implemented. This type of document could
be created electronically or hard-copies could be printed and require the signatures of those staff

members who develop and check the plans.

The RO-ILS systematic approach to documenting mistakes, identifying solutions, and

making these occurrences available for educational purposes to departments around the world

only makes the radiation oncology field more effective and safe for those who are affected or

employed in the field. Simple mistakes are common and it is important to identify and prevent

them from occurring in the future. Communication between members of a department can often

be sacrificed for a variety of reasons and this can lead to a disconnect, as was evident in the study

discussed. The RO-ILS system is designed to recognize the root of a problem and offer solutions

such as clearly documenting prescriptions and creating checklists that remind the planner,

physician, and physicist to verify crucial portions of a plan. The radiation oncology field

inevitably experiences mistakes but having an organization that seeks to limit and prevent these

mistakes will help to save lives, money, and time.

1. RO-ILS- American Society for Radiation Oncology (ASTRO) - American Society for
Radiation Oncology (ASTRO). ASTRO - American Society for Radiation Oncology
(ASTRO). https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS.
Accessed September 28, 2018.
2. Blumberg A, Burns A, Cagle S. Safety is No Accident. [ASTRO]. July 2012. Accessed
September 28, 2018.
3. American Society for Radiation Oncology (ASTRO) - American Society for Radiation
Oncology (ASTRO). ASTRO - American Society for Radiation Oncology (ASTRO).
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS/RO-ILS-
Education. Accessed September 28, 2018.