1
Noelle Deiter
DOS 518
Professional Issues
Radiation Oncology Incident Learning System (ROILS) Case Study
In 2010, The New York Times featured articles about radiation therapy accidents
happening around the United States.1 These articles caused extreme concern and prompted action
from the medical community. In response to these events, the American Association of Physicists
(AAPM) and the American Society of Radiation Oncology (ASTRO) conducted a meeting called
“Safety in Radiation Therapy: A Call to Action”. The goals of the meeting were to determine the
root causes of errors and design an action plan to reduce errors. A key component was the
initiation of a radiation oncology incident learning system (ROILS) in 2011.
The radiation oncology incident learning system is a federally protected web-based
system where professionals enter error reports. The data is anonymized and made nationally
available to promote education and awareness. This system is a crucial tool for individuals in the
field of radiation oncology. It has helped identify situations that cause errors and develop a
culture of safety, learning, and accountability.2
A specific case from the ROILS revealed an error in daily dose and fractionation due to
poor communication between the medical dosimetrist and radiation oncologist. The medical
dosimetrist received a verbal order for a total dose of 3,600 cGy. A prescription of 180 cGy per
day for 20 fractions was entered in the patient’s chart by the medical dosimetrist. The radiation
oncologist approved the plan. After 9 treatments, the radiation oncologist was not seeing the
desired changes in the patient’s tumor. This is when the physician became aware of the incorrect
daily dose in the patient’s chart. The intended daily dose was 300 cGy delivered over 12
fractions.
Two major factors which contributed to this error include lack of documentation for the
intended prescription and lack of procedural pause communication between the radiation
oncologist and medical dosimetrist. Hendee et al1 identified declaring a time out and establishing
standards of practice as key action items in error reduction. Each team-member should be
committed to these practices and responsible for patient safety.1 Therefore, both the radiation
oncologist and medical dosimetrist would be responsible for verifying the prescription.
2
Addressing prior mistakes and implementing changes of practice are effective ways
improve safety in radiation oncology.2 For this type of case, a procedural pause or a time out
(TO) process could be implemented to prevent error. This process could include key items such
as patient name, anatomical site, daily dose, fractionation, and total dose.4 Rasmussen et
al3 assessed 6 years of data from 5 institutions to demonstrate effectiveness of TO processes.
Results showed a 3-fold reduction in error rates.3
Another action to prevent this type of error would be prescription standardization.
Although communication plays an obvious role in clinical outcomes, Evans et al4 suggests
prescriptions should be presented in a standard way to reduce errors. The formal presentation
should include dose per fraction, fraction number, and total dose. Units of dose should be
expressed in cGy instead of Gy. This method eliminates decimal points and provides a clearer
interpretation of dose. For example, 3 x 10 could be interpreted various ways. Re-phrasing this
statement to 3000 x 10 would be more easily understood and imply 3000 cGy. Attempting to
standardize prescription formatting across institutions remains challenging and will need future
efforts to improve patient safety.
In summary, the prescription error reported in this case was due to deficiencies in
communication and omission of procedural pause prior to plan approval. In effort to prevent this
error from reaching another patient, a verbal and written check of daily dose, fractionation, and
total dose should be implemented between the medical dosimetrist and radiation oncologist. On a
larger scale, efforts should be made to standardize prescription formats across different planning
systems.
Overall, the ROILS has encouraged higher standards in quality care. This effort includes
not only the radiation therapy team, but also vendors, and regulatory agencies that must remain
committed to patient safety. Errors like the case of incorrect daily dose and fractionation can now
be measured and shared. Institutions who have joined ROILS can access error information and
use analysis tools to improve their procedures. With this pledge and action toward safety, a
higher level of trust can be cultivated among patients, radiation oncology professionals, and the
public.
3
References
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. Rasmussen B, Chu K. TH‐C‐203‐04: Implementation of a “Time Out” Procedure in
Radiation Oncology: A Multi‐Institution Study over Nine Years Results in a Three‐Fold
Reduction in Misadministrations. Med Phys. 2010;6(37):3450-3451. http://
dx.doi.org/10.1118/1.3469477
4. Evans S, Benedick F, Berner P, Collins K, Nurushey T, O’Neill M, et al. Standardizing
dose prescriptions: An ASTRO white paper. Practical Radiation Oncology. 2016;6:
e369–e381. http:// dx.doi.org/10.1016/j.prro.2016.08.007
