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ROILS System Case 1
I decided to address the issue known as Case 1: Planner wrote prescription for the
physician to sign. In this case, the medical 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. There are many apparent factors that could have led to this
error.
Like many problems, the factors leading to this error is likely in the process more than in
the people.1 The primary issue I noticed was the mentioning of a verbal order from the physician.
In todays world of electronic medical records, paper charts with a handwritten physician
prescription seems to be a thing of the past. Without written or typed documentation of a
prescription, the dosimetrist and additional physics staff has no authority to set an assumed
prescription dose. In our field of radiation oncology, which is extremely technical, an extensive
and well documented plan of the details for patient care is essential.2 In this case, if
documentation were done correctly and in a timely manner by the physician, it would be safe to
assume that the dosimetrist did not review those documents prior to beginning the planning
process. In preparation for each patient to undergo treatment, the physician documents a clinical
treatment. The clinical treatment planning is a formally documented and approved directive for
any pretreatment preparation that specifies area(s) of treatment, dose, dose fractionation and the
treatment schedule.2 Because the clinical treatment plan including the dose fractionation
information is to be completed for the simulation or prior to treatment, it must have been
overlooked by the dosimetrist. To eliminate this error for future patients, it is imperative that the
dosimetrist reviews the written record of the clinical treatment plan prior to sending the plan for
physician review. Upon physician review, the physician needs to be sure to click on the
prescription information and confirm that the total dose, fractionation, and scaling factor has
been appropriately applied. Also, during the second check process by the additional physics staff,
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it is crucial that the physicist reviews the written record of the total dose and fractionation
scheme prior to considering the plan to have a final approval making it ready for treatment.
The second major event leading to this error comes from a multitude of assumptions that
have not been addressed in the information about the case. When beginning the planning process,
the dosimetrist has likely been informed of the tumor type in origin. Because the physician
wanted 300cGy per treatment, I would venture to assume that the situation may have been
palliative in nature. If this case were palliative, I would never assume that the physician would
choose 180cGy per fraction each day. As a certified medical dosimetrist, if I had any question
about the prescription or why a dose was chosen, I never hesitate to confirm the patient treatment
plan with the physician. Secondly, it was mentioned that the physician saw the patient in the
clinic after the 9th fraction, which is when it was noticed that the tumor had not responded as
expected, leading to referencing the treatment plan in the electronic medical record. It is not
mentioned if the physician had seen the patient the week prior to this 9th fraction, which would
have been the patient’s first week of treatment. Had the physician seen the patient the week prior,
it would be assumed that the physician did not review the patient’s electronic medical record
before seeing them in the clinic. In order to eliminate this error for future patients, the medical
dosimetrist needs to remain focused at all times, never hesitating to speak personally with the
physician if any treatment planning parameters are in question. Of course, the final decision in
regards to the prescription is always in the hands of the physician, we still need to remember that
physicians too are humans and have made mistakes as well. So, the more that we can all be on
alert, the better care we can provide to each and every patient. Also, the physician must be
provided with access to the electronic medical record of each patient prior to seeing them for
weekly progress. If the medical record is not readily available, more mistakes may ensue and
important patient details could be missed.
Mistakes will be made, no matter how particular work may be done. Because we are
human beings, we will never be perfect. However, the goal needs to remain to reduce the reasons
that errors are often made. In most situations, employees make errors because of lack of training,
poor communication, inadequate tools, insufficient planning, incomplete procedures, and lack of
attention.1 Medical dosimetrists should always be board certified and completely familiar with
the treatment planning system used in their clinic, which should reduce errors due to lack of
training. The radiation oncologist, medical physicist, medical dosimetrist, radiation therapist and
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oncology nurses should always be in communication to eliminate patient specific misconceptions
in proper treatment. The clinic should always try to have the best possible equipment and replace
any items as needed, eliminating errors due to inadequate tools. To eliminate errors due to
insufficient planning, incomplete procedures and lack of attention go together in our field of
medical physics. The radiation oncologist must communicate the treatment plan to the physics
staff, ensuring that the clinical treatment plan is completed in a timely manner for the treatment
planning process. Then, each member of the physics staff must do their part for each patient’s
treatment plan. After the plan has been completed by one staff member, the responsibly is just as
important on the additional physics staff member that is second checking the plan. If the
processes are followed appropriately, errors will be limited and hopefully found prior to ever
causing patient harm.
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References
1. Lenards, Nishele. Continuous Quality Improvement. [Soft Chalk.] La Crosse, WI: UW-L
Medical Dosimetry Program; 2019.
2. Safety is No Accident - American Society for Radiation Oncology (ASTRO) - American
Society for Radiation Oncology (ASTRO). ASTRO. https://www.astro.org/Patient-Care-
and-Research/Patient-Safety/Safety-is-no-Accident. Published March 2019. Accessed
October 7, 2020.
