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Benjamin Smith
DOS 518: Professional Issues
October 12, 2020

ROILS Case Study 1

Within the field of radiation oncology, there are many quality assurance procedures

manifested to assure the patient is treated accurately and safely. However, there are many

treatment errors that still occur which are documented and submitted for review. The

organizations ASTRO and AAPM formed a national reporting system known as the ROILS

System which highlights several incidences where a radiation treatment error has occurred.

For the ROILS case study I am reviewing, we are given the following scenario involving

the wrong fractionation/prescription used for treatment. The physician verbally told the

dosimetrist to create a plan for a total dose of 3600 cGy. The dosimetrist proceeded to enter the

prescription in the patient’s electronic medical record (EMR) for 180 cGy x 20 fractions = 3600

cGy. This was not what the physician had intended as the correct prescription was 300 cGy x 12

= 3600 cGy. Nevertheless, the plan with the incorrect fractionation was approved by the

physician with the radiation therapy treatment implemented for several days before being caught

by the physician after noticing the lack of tumor regression during a weekly clinical visit.

There are several factors that need to be addressed that led to this treatment error. The

primary issue is the dosimetrist entering the prescription for the patient in their EMR. Part of the

radiation oncologist’s designated responsibilities include documenting the total desired dose and

fractionation along with treatment technique, energy, pre-treatment imaging requests as well as

any other details regarding the patient’s prescription.1 At my clinical facility, the attending

physicians not only fill out the sim intent for each patient but also utilize the “Prescribe

Treatment” page in ARIA to create a draft of the prescription they have designated for that
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specific patient. The dosimetrists do not begin planning until the physician has filled out the

prescription tab. After the dosimetrist has created a treatment plan, he or she reviews it with the

attending physician. If the plan is verbally approved, the physician will proceed to manually

approve/sign the prescription. The reason why they do not approve the prescription from the start

is the chance the energy(ies) or treatment technique have changed from their original intent. The

draft of the prescription can be amended to account for energy or treatment technique changes

before final approval. This process may seem superfluous but it helps prevent any prescription

errors such as the one found in this case study.

Due to the fact that this treatment error was not caught until a week into treatment, it is

safe to assume that physics also did their QA check on the plan as well. This pretreatment QA is

required for safe and high-quality radiation therapy for the patients.2 In this instance, they did not

catch this error which also could have prevented the patient from being mistreated. This

secondary check by the physicist includes completely reviewing the physician-approved plan,

identifying any errors after analyzing the dose distribution to the targets and critical structures as

well as other checks.2 In this particular case, it may prove difficult for the physicist to identify

the prescription error if the physician approved the plan with the wrong entered prescription and

the plan matches accordingly. At my clinical facility, our team of physicists review each

treatment plan with a fine-toothed comb which may seem tedious at times but ensures that the

plans are safe for treatment.

Lastly, I wanted to discuss another important element that could have prevented this

treatment error. Peer review is imperative in the field of radiation oncology as it allows a 2nd or

3rd set of eyes to gauge the plan and voice any concerns. Peer review can involve any of the

following: intradisciplinary (physician to physician), interdisciplinary (amongst the radiation

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oncology clinical team), and multidisciplinary (with other specialties).2 Peer review is important

for the safe delivery of radiation but even more crucial is the timing of peer review.2 Peer review

should be held prior to the treatment of the patients; therefore, appropriate measures can be taken

prior to treatment to correct any issues that may arise. Had a prospective peer review occurred

for this case of interest, either the attending physician would have seen the wrong prescription

being presented or another physician may have questioned it. At my clinical facility, peer review

is conducted 3 days a week in order to have every case presented prior to the start of their

radiation treatment. The dosimetrists upload a PDF file of the treatment plan highlighting

everything from the diagnosis, prescription with fractionation, target volumes and dose

outcomes. The dosimetrists also document which cases were sent to peer review as well as

which ones were actually presented in conference.

The treatment error in this case study could have easily been avoided had the attending

physician manually entered a prescription in the patient’s chart and not the dosimetrist taking

that duty upon his/herself as that is not part of their job description. The secondary checks by the

physicist could have also caught this error but would have been more challenging. Finally, peer

review of the case prior to treatment would have allowed the attending physician and other

faculty to question the entered prescription which would have enabled the plan to be corrected

before the patient ever was treated.

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References

1. Ezzell G, Chera B, Dicker A, et al. Common error pathways seen in the RO-ILS data that
demonstrate opportunities for improving treatment safety. Pract Radiat Oncol.
2018;8(2):123-132. http://doi.org/10.1016/j.prro.2017.10.007
2. American Society for Radiation Oncology (ASTRO). Safety is No Accident- a
framework for quality radiation oncology care. ASTRO website.
https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and
%20Research/PDFs/Safety_is_No_Accident.pdf. Published 2019. Accessed October 7,
2020.