Zachary Casto

DOS 518: Professional Issues in Medical Dosimetry

Radiation Oncology Incident Learning System (ROILS) Cast Study

With modern advancements in radiation oncology treatment methods and machine

capabilities, there too must be equal advancements made in their quality assurance programs and

patient safety awareness. For instance, a series of articles about radiation therapy accidents

happening around the United States of America were published by the New York Times in

2010.1 These articles brought to everyone's attention great concerns for patient safety and thus

prompted action from the professional medical community. As a result, the American

Association of Physicists (AAPM) and the American Society of Radiation Oncology (ASTRO)

held a meeting called “Safety in Radiation Therapy: A Call to Action.” The goal of this meeting

was to determine the root causes of errors and design an action plan to reduce them. A key

development in incident reporting was created called the radiation oncology incident learning

system (ROILS) in 2011. This ROILS program allows for anonymized incident reporting from a

single institution and then it is available nationwide to all participating institutions in the ROILS

program to learn from and to help identify situations that caused the initial error and to develop a

culture of safety, learning, accountability and processes to avoid committing the same

mistakes/errors again.2

One specific case that was logged into the ROILS system included an error in daily dose

and fractionation scheme due to a verbal order from the physician to a medical dosimetrist to

plan a patient's treatment to a total of 3600 cGy. The dosimetrist then proceeded to create a plan

designed to deliver the 3600 cGy in 20 fractions, 180 cGy per fraction; however, the physician

did not relay that they wanted the plan to deliver the 3600 cGy in 12 fractions, 300 cGy per
fraction. The plan created by the medical dosimetrist was approved for treatment. After 9

fractions had been delivered, the physician noticed the mistake when there was a failure to

achieve the expected tumor regression at this point in treatment.

One major factor that contributed to this treatment error would be the lack of adequate

documentation and treatment prescription standardization.3 A good standardized format for a

treatment prescription would include the total dose, dose per fraction, and the number of

fractions. In addition, the units of dose should be consistently expressed and labeled in either

cGy or Gy to avoid confusion in dose representation. If done correctly, the dosimetrist can take

the total dose and divide it by the fractionation scheme to verify that the dose per fraction is

found to be the same dose per fraction requested in the prescription prior to planning. This quick

calculation serves as a quick second check of the physicians’ prescription at an early stage in the

planning process.

Another major factor that contributed to this treatment error would be the lack of a

thorough time out or second check. Hendee at al1 declared that performing a time out and

secondary check by all parties involved with the safety of the patient can lead to a reduction in

error. Following this suggestion, not only are the medical dosimetrist and physician responsible

for confirming the treatment prescription and resulting treatment plan, but also the radiation

therapists who deliver the treatment plan and the radiation physics staff who run quality

assurance and safety checks on the treatment plan. If followed, this would mean that every

treatment plan would have been looked over by 4 different individuals prior to delivering the

first treatment to the patient. Staff could also perform a daily in room time out with the patient to

verify the correct patients’ treatment plan is pulled up on the treatment console, confirm the
treatment site, and then at the end of treatment, verify that the correct dose and fraction has been

recorded in the patients' medical record.

This case is a prime example of why there is a need for the ROILS program and for

facilities to actively enroll and participate in it. Errors much like this can now be reported and the

root cause can be determined and a plan to further prevent similar future situations/errors from

arising can be implemented not just at the clinical site where the error first occurred but to other

participating facilities. The ROILS program offers a type of shared learning based on

experiences in the radiation oncology field that has helped promote a higher standard in quality

care. Ultimately, a culture that recognizes safety challenges and creates viable solutions to

counteract these weaknesses must be maintained not only by the treatment facility, but also

equipment vendors and regulatory agencies.4

 Refernces

1. Hendee W, Herman M. Improving patient safety in radiation oncology. Med Phys.

2011;38(1):78-82.
2. Digiulio S. Redefining safety in radiation oncology. Oncology Times. 2014;36(23):14-15.
3. Evans S, Benedick F, Berner P et al. Standardizing dose prescriptions: An ASTRO white
paper. Practical Rad Onc. 2016;6:369-381. http://doi.org/10.1016/j.prro.2016.08.007
4. Rodziewics TL, Hipskind JE. Medical error prevention. StatPearls.
https://www.ncbi.nlm.gov/books.NBK499956/. Accessed October 10, 2020.