Everybody makes mistakes. In the medical field, mistakes can be costly and fatal.

When
mistakes happen, best practice is to investigate and understand the root cause of the error, so that
changes can be made to ensure the error doesn't reoccur. Some causes of potential error are
universal - each medical center is likely to experience their own failure of systems similar to
other medical centers when there is room for a potential source of error within a process. Instead
of waiting for an error to occur, and retroactively attempting to find a solution - after a
potentially serious incident - the medical community can learn from one another by sharing
identified sources of error and steps taken to eliminate that source.
In the UK, there exists a national reporting system for the entire health system that
interfaces directly with many hospital-based reporting solutions, such as Datix.1 Incidents
(including near-misses or otherwise) are uploaded, categorized, and frequently published along
with steps the originating facility has taken to remove the source of error. These reports are
accessible by anyone, and facilities frequently disseminate relevant reports amongst their
employees as encouragement to check their processes and procedures for any similar gaps. In the
US, given the disparate and competitive nature of healthcare facilities, this kind of reporting
system is not as prevalent or as easily implemented.
Radiation oncology is medical specialty where errors and mistakes can have serious
consequences. Committed to continuously improving patient care, the American Society for
Radiation Oncology (ASTRO) joined forces with the American Association for Physicists in
Medicine (AAPM) in 2014 to launch the Radiation Oncology Incident Learning System (RO-
ILS).2 Protected by federal law established in the Patient Safety and Quality Improvement Act
(PSQIA) of 2004, RO-ILS allows facilities to examine and learn from patient safety events or
incidents without fear of liability or legal retaliation. There is no requirement for facilities to
participate in RO-ILS, but doing so allows the radiation oncology community to learn from one
another and help eliminate needless errors.
Each quarter, analysts will identify any trends occurring nationally and compile a report
highlighting key areas of concern and suggested measures to be implemented to lessen the
incidence of errors of a particular type from occurring. The report also often contains case
studies from facilities that illustrate the type of error occurring. A common trend across quarterly
reports issued within the last several years concerns prescribing or prescription errors. One such
case study involving an error of this type was published in Quarterly Report: Patient Safety
Work Product3 for the third quarter of 2017. The incident occurred when a physician verbally
requested the dosimetrist to generate a plan to 36 Gy. The resultant plan was approved by the
physician and delivered by the therapists. After the 9th fraction, during an on-treatment review of
the patient, the physician was concerned about the lack of tumor regression. This led to the
realization that the physician’s treatment intent had been to deliver 12 fractions of 300 cGy each
totaling 36 Gy, whereas the dosimetrist had entered the prescription as 20 fractions of 180 cGy
each, also totaling 36 Gy.
There are several failures within the planning process that allow this type of error to
occur. Verbal requests form part of a phenomenon called 'corridor conversations'. This type of
communication has many advantages in specific scenarios, but can also lead to
miscommunication and misunderstanding.4 Following a corridor conversation, a professional
may engage in other activities or matters before needing to recall and utilize the information
provided verbally. In situations such as these, it can be easy to misremember vital information,
particularly that which is numerical or different to common standards. In the reported case study,
the prescription was communicated to the dosimetrist verbally and was not complete in the sense
that it did not contain any information regarding fractionation. Following the generation of a plan
to 36 Gy, the physician then approved the plan without realizing that the prescription was not
what s/he had intended to deliver. This is another failure of procedure. It appears that in both
cases, assumptions had been made, but not confirmed. The dosimetrist assumed a particular
fractionation was required, whereas the physician had assumed that the prescription entered was
correct.
Prior to issuance of the 2017 Q3 RO-ILS report, an ASTRO white paper entitled
Standardizing Dose Prescriptions5 was published in the November-December 2016 issue of
Practical Radiation Oncology. The white paper outlines a framework for standardizing
prescriptions, including minimum requirements for a prescription to be valid. The required
elements include the anatomic treatment site, total dose, dose per fraction, and the method of
delivery. These elements are required to be provided by the physician prior to the start of
treatment planning, as detailed in the directive concerning the physician’s role and
responsibilities that form part of ASTRO’s Accreditation Program for Excellence (APex).
Providing complete prescription details prior to treatment planning ensures that there is no
ambiguity regarding intent. Within the health system, any other physician-ordered prescription
for controlled drugs must contain minimum criteria such as dosing strength and frequency in
order to comply with state and federal laws.6 It seems an anomaly that prescriptions for radiation
are not governed by the same regulations and laws.
Other recommendations within the ASTRO white paper include further prescription
standardization. In some facilities, the dosimetrist may fill out the prescription for the physician
to sign when approving the plan, in others the physician may complete a temporary prescription
prior to patient simulation that is revised when planning is complete. In any case, workflow
should be standardized throughout the department, so that each member of the team is aware of
their responsibilities at each step throughout the process. Furthermore, if the physician is not the
person entering the prescription attached to the plan, there should exist a task whereby the
physician is required to manually confirm each element of the prescription prior to final plan
approval or treatment.
Facility accreditation by ASTRO requires that the physician provides a complete
prescription prior to treatment planning and this should be formally documented within the
patient’s medical record. A pre-planning prescription directive within the patient’s medical
record allows the prescription intent to be verified against the plan in each of the pathway checks
– by the physicist, and therapist prior to treatment. Errors can easily propagate and pass through
double checks, particularly if there are no reference documents to validate information against,
or there is no standardized procedure for that particular task. Workflows or checklists covering
all essential information to be checked can increase compliance and ensure that no element is
missed. Implementing checklists within the healthcare setting have consistently improved patient
safety.7
Patient safety is, or should be, a priority within the radiation oncology department. Given
the potential to cause fatal damage, practices should be standardized and examined for potential
sources of error. Failure Mode and Effects Analysis (FMEA) is one way of doing this, but is
facility or department-specific. Systems like RO-ILS allow the professional community to
examine trends and to learn from process failures in other institutions. The more sources of error
that are identified, the greater opportunity there is to improve procedures to help eliminate these
errors.

References:
1. Report a patient safety incident. National Health Service. Improvement.nhs.uk.
https://improvement.nhs.uk/resources/report-patient-safety-incident/. Published 2017.
Accessed October 5, 2019.

2. RO-ILS Background - American Society for Radiation Oncology (ASTRO). ASTRO.

https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS/RO-ILS-
Background. Published 2019. Accessed October 5, 2019.

3. Radiation Oncology Incident Learning System (RO-ILS). Quarterly Report Patient Safety
Work Product. Chicago: Clarity PSO; 2017.
https://www.astro.org/ASTRO/media/ASTRO/Patient Care and Research/PDFs/ROILS-
Q3_2017_Report.pdf. Accessed October 5, 2019.

4. Long D, Iedema R, Lee B.B. Corridor Conversations: Clinical Communication in Casual

Spaces. In: Iedema R, ed. The Discourse of Hospital Communication. London: Palgrave
Macmillan; 2007:182-200. https://doi.org/10.1057/9780230595477_9.

5. Evans S, Fraass B, Berner P 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

6. Drug Enforcement Administration. Practitioner’s Manual: An Informational Outline of the

Controlled Substances Act. Washington D.C: United States Department of Justice; 2006.

7. Checklists to improve patient safety. Health Research & Educational Trust.

http://www.hpoe.org/checklists-improve-patient-safety. Published 2013. Accessed
October 5, 2019.