Keegan Sanborn

DOS 518
10/25/22

ROILS Review: Case Study One

Radiation is a widely misunderstood form of treatment in today’s world. It has long been

associated with nuclear war or obscene side effects like glowing in the dark. The field of

radiation oncology seems to be held to a higher standard when it comes to mistakes for this

reason. When mistakes happen in our field, they are written about in a way that casts a dark

shadow over the effort many members have taken over the years to ensure that radiation is safe

and has a wide range of benefits. There are many ways we can continue to grow as a field to

ensure the safety of the patients we treat daily, one of them being examining past mistakes.

In this case study, a mistake was made resulting from a lack of communication between a

dosimetrist and radiation oncologist. The dosimetrist took a verbal order from the physician to

generate a plan with a total dose of 3600 cGy. The physician’s intent was to treat the patient in

12 fractions, with a fractionated dose of 300 cGy to the total of 3600 cGy. The dosimetrist

assumed that the physician wanted 20 fractions, at 180 cGy per fraction to a total dose of 3600

cGy. The physician ended up approving the plan and it was exported to the treatment unit. This

mistake was not realized until the second week of treatment when the physician was surprised

by the lack of tumor regression. The physician checked the medical record and discovered that

the incorrect fractional dosage was being administered to the patient.

The error pathway began when the verbal order wasn’t clarified by the dosimetrist.

Physicians sometimes forget the hierarchy of the department when they get busy. As they juggle

visiting patients, approving plans, contouring, approving insurance or a million other things,

certain tasks may get handed to someone else without proper communication. It should be the

physician’s responsibility to assign fractionation in patient’s charts or at least document the

intent for other staff to see. The physician assumed the dosimetrist understood the order, and

the dosimetrist assumed the physician wanted “standard” fractionation. If there had been proper

communication from the beginning, this problem could have been avoided in seconds. The World

Health Organization (WHO) wrote a report detailing what common incidents led to adverse

effects when treating patients with radiation. In this report, most errors were caused by a

communication failure (38%).1 In any medical field, communication is key, and it generally starts

with the physician. In this case, the lack of communication from the physician and the lack of

clarification from the dosimetrist ultimately led to this patient being mistreated.

I feel a second contributing factor that led to this error is an inadequate second check

performed by physicists and/or therapists. If a proper chart check had been performed, a lack of

physician approval of the prescription would have been noticed. There are many fast-moving

parts in radiation oncology, so performing second checks on other staff members’ work offers a

way to catch errors that may have been overlooked. Yeung et al2, states in their article on quality

assurance, “that although not officially documented, in our clinic, clinical prescriptions are

routinely checked by the planner during the treatment planning process and by the therapist at

the machine before treatment starts. If anyone has any concern about a particular prescription,

he/she will contact the oncologist for confirmation.” 180 cGy fractionation is extremely common

for treatment, so this probably didn’t raise any red flags, but while in the process of checking

over the patient record, a clarification call to the physician would have helped ensure safe

treatment for the patient.

There are a few simple solutions that could be implemented in clinics to help prevent this

situation from happening to another patient. A rule could be made to only allow delivery of

treatment with a signed order of the prescription from the physician. This can be an actual

document, a note in the patient’s chart or the physician’s electronic initials next to the

prescription that was entered by another party. This solution could even be taken a step further
in that a dosimetrist wouldn’t be able to plan any treatments unless the physician had signed the

document indicating the correct prescription. This could be done at the time of physician

contouring or shortly after. From personal experience, I know that if this were the case,

physicians would put the note in rather quickly due to a hoard of dosimetrists breathing down

their neck wondering what direction to take the plan in. If either of those solutions were put in

place, it could drastically help limit errors that result from a lack of communication.

Communication plays a vital role in radiation oncology. There are various roles to fill with

a lot of moving parts. Clinic checkpoints can be put in place to help slow down staff and truly

double check the safety and feasibility of treatment delivery. This case didn’t result in drastic

injury for the patient, but it does cause concern for the effectiveness of treatment. Overall,

verbal communication should be encouraged in medicine, but it should also be encouraged to ask

questions or clarify with others so that the patient’s safety remains our top priority.
 References

1. Greenwalt JC, Mittauer K, Liu C, Deraniyagala RL, Yeung AR. Reducing errors in
radiation treatment through the implementation of electronic safety checklists.
International Journal of Radiation Oncology*Biology*Physics. 2014;90(1).
doi:10.1016/j.ijrobp.2014.05.574

2. Yeung TK, Bortolotto K, Cosby S, Hoar M, Lederer E. Quality assurance in

radiotherapy: Evaluation of errors and incidents recorded over a 10 year period.
Radiotherapy and Oncology. 2005;74(3):283-291. doi:10.1016/j.radonc.2004.12.003