Case Two: Weekend treatment, misread caliper

A patient required whole brain radiation over the weekend. Two therapists and the physician
were present for the patient's setup. The patient was setup clinically on the treatment unit. One
therapist measured the patient's head with a lateral separation of 30 cm using the incorrect scale
side on the calipers. This resulted in a 28% in dose over 2 weekend treatments. The error was
caught on Monday by the Dosimetrist when a formal plan was completed.

An error occurs when a process does not proceed the way it was intended by its designers
and managers.1 Every radiation oncology facility is vulnerable to errors in the clinic and so it is
important to improve the processes used in radiation treatment delivery to minimize these errors.
Patient clinical setups in radiation oncology are associated with increased risk of treatment errors
because they usually involve manual data entry and lack the use of record and verify systems.2,3
The pathway for the above-mentioned error is as follows:
• Two therapists and one physician were present for the clinical set-up without a medical
dosimetrist or medical physicist.
• Only one therapist measures the patient’s lateral separation and was not verified by the
other therapist.
• The therapist measures the lateral separation without picture documentation showing the
lateral separation on the caliper at the time the measurement was taken.
• The medical dosimetrist discovers the error when a formal plan was done

One of the contributing factors that led to the error was having only one radiation therapist
measure the lateral separation without being verified by the other radiation therapist. In
specialized treatments such as radiation therapy, it is important to have verification checks for
every step of the process leading to the treatment delivery. The error could have been picked up
by the other radiation therapist if it was verified at the time of the measurement. To prevent this
from happening, a clear and well-written policy and procedure must be developed to mandate
double-checking of data measurements, treatment parameters, and patient set ups.
Besides, picture documentation showing the lateral separation on the caliper at the time
the measurement was taken, could have helped prevent this error. As part of the quality
assurance process, medical physicists and radiation oncologists must review and sign-off
documentation of treatment parameters and set-ups before the treatment delivery. Picture
documentation showing the lateral separation may have been reviewed or verified by the medical
physicist and the error would have been prevented. Checklists should be developed by medical
physicists to check the correctness of manual data entries including picture documentations.
The use of CT simulation for this patient could have prevented the wrong measurement
of the lateral separation of the patient. Computed Tomography simulation digitally generates
accurate three-dimensional patient anatomy and eliminates the manual measurement of the
lateral separation. The use of CT simulation is part of the process of generating a formal plan. As
stated in this incident report, the error was discovered after a formal plan was completed.
Therefore, it is essential to eliminate clinical set-ups in this age of technological advancements in
radiation oncology to reduce errors as a result of manual data measurements and entries. It is also
important to note that, while the use of record and verify systems in radiation therapy has been
found to reduce manual data entries, it could also result in errors since these systems largely
focus on enhancing efficiency rather than quality assurance systems.4,5
Lastly, radiation therapists, medical dosimetrists, and medical physicists must be trained
to develop intuitive knowledge of the correctness of treatment plan parameters such as
separation, monitor units, and treatment delivery. This knowledge would help them question the
correctness of the lateral separation of ‘30cm’ for the head(brain) which is intuitively high and
unusual for an average patient.

References
1. Lenards N. Continuous quality improvement. [SoftChalk]. La Crosse, WI: UW-L
Medical Dosimetry Program;2020. Accessed October 10, 2020.
2. Germond JF, Haefliger JM. Electronic dataflow management in radiotherapy: Routine
use of the DICOM-RT protocol. Cancer Radiother. 200;5(1):172s-180S
https://pubmed.ncbi.nlm.nih.gov/11797279/
3. Klein EE, Drzymala RE, Purdy JA, Michalski J: Errors in radiation oncology. A study in
pathways and dosimetric impact. Appl Clin Med Phys. 2005;6:81-94.
http://doi.org/10.1120/jacmp.v6i3.2105
4. Patton GA, Gaffney DK, Moeller JH. Facilitation of radiotherapeutic error by
computerized record and verify systems. Int J Radiat Oncol Biol Phys. 2003;56(1):50-57
http://doi.org/10.1016/s0360-3016(02)04418-8
5. Bogdanich W. Radiation offers new cures, and ways to do harm. The New York Times.
2010. Accessed October 10, 2020.
https://www.nytimes.com/2010/01/24/health/24radiation.html?mcubz=0