Reta Zeto

ROILS Incident
October 30, 2022

In radiation oncology, or any healthcare profession, the goal of the department and the
professionals working is to provide the safest and best quality of care to the patients. Including
and most importantly the radiation therapy treatments they are coming in to receive. The
department sets many guidelines and procedures that need to be followed to accomplish the
highest quality of care. ASTRO which stands for American Society for Radiation Oncology is a
professional organization that has many programs in place for patient safety and high-quality
care. They have set standards and guidelines for healthcare facilities to follow and have access to
so they can keep improving their departments. Safety is no accident is a reference guide that was
released in 2019 and discusses how to improve quality and safety as well as radiation oncology
process of care and describing the clinical team and their jobs.1 They have also launched a safety
program called Target Safety which focuses on ASTRO improving patient safety and reducing
the medical errors during radiation therapy treatments.2 This also supports the ROILS (Radiation
Oncology Incident Learning System), it strengthens radiation oncology departments through
their APEx program, also providing cancer survivors with support groups a list of questions that
patients should as the doctor when deciding to go through radiation therapy treatments. The
ROILS program provides information on providing safer and higher quality care in radiation
oncology. This mechanism is for shared learning in a secure and non-punitive environment.3 This
is the only medical sponsored incident learning system for radiation oncology, and it will provide
an opportunity for shared learning across all radiation oncology healthcare facilities.

In the ROILS reports that have been recorded from different healthcare facilities there
has been an incident that happened that was between a doctor and the dosimetrist. The
dosimetrist was told by the physician to do a plan going to 3600 cGy and entered the prescription
in the electronic medical record. The doctor wanted 300 cGy times 12 fractions which equal to
3600 cGy total but the plan made by the dosimetrist was for 180 cGy times 20 fractions equaling
to 3600 cGy total, which is incorrect. The doctor approved the plan, and the plan was then
exported to the treatment machine to be delivered. The patient received 9 treatments and was
seen in clinic after that treatment. The doctor was surprised by the lack of tumor regression and
looked in the chart and noticed that the daily dose was not 300 cGy but 180 cGy a day.

One contributing factor to a situation like this would be the communication between the
dosimetrist and the doctor. This was a big miscommunication between the two as to what the
doctor wanted or intended the prescription to be and what the dosimetrist understood it to be.
Since this was verbal communication, nothing was written down to go back to and double check,
so the treatment prescription was written incorrectly. Verbal communication is ok at times, but a
person may not always remember the details they are told in a situation where they could’ve
misheard the instructions. This causes common errors, which in a field like radiation oncology
we can’t afford to have. Another factor that contributed to this error could simply be human
error. The dosimetrist could have accidentally typed the wrong daily dose and number of
fractions so therefore planning incorrectly. There needs to be clear communication between the
doctor and dosimetrist so errors like this don’t occur and end up in not planning correctly and
mistreating the patient. Everything should be written down from the doctor to ensure the correct
prescription is given. Some dosimetrists have a good relationship with the doctor and know
exactly what they want for their prescriptions so they may not need to have it on paper or in the
record and verify system. If someone who doesn’t know what the doctor wants doesn’t clarify
the prescription with them then this mistake could easily happen. Everything that has to do with
patient information should be written down so everything is documented, and everyone receives
the same information.

Some suggestions to improve this process could be a that the department sets policies for
the dosimetry department to make sure that everything is double checked and no form of verbal
communication regarding patient information and planning is done. There can be a QCL
checklist for the dosimetry team to double check the prescription and plan. This can also be
checked by the doctor prior to the first treatment for the patient. Another solution can be is
having a “peer review” done on all treatment plans from fellow dosimetrists. This can limit
errors because it would be a different person looking at all the treatment information. They can
question what seems off and then it can be reviewed and be caught before it goes out to the
radiation therapists to begin treatment. If a second pair of eyes would have checked on this plan
before it went out, it could’ve been caught and not harmed the patient with 9 fractions being
incorrect. The radiation oncology department must be constantly vigilant because no computer
system can compensate for a team member’s error in judgment, misunderstanding of physical
concepts or technological limitations, or unsatisfactory planning and delivery of radiation
therapy.4 Computers aren’t always trustworthy and won’t catch on human error, so as
professionals that input information into these smart systems, we must be cautious as to what is
being put into these systems.

The responsibility of healthcare professionals is to always ensure great quality and safe
patient care at all times. We must do our best to make sure the information that is going out to
the treatment floor is correct and the absolute best we have done in regard to the treatment
planning. Good communication, QCL checklists, and peer reviews are great ways to minimize
errors in radiation therapy planning. Doctors, the physicists, and dosimetrists should always have
clear and precise communication to ensure minimal errors for the best quality of care to the
patient. If errors do happen then as healthcare professionals, we should be able to identify them,
fix them, and implement ways to make sure the mistakes don’t happen again.
 References
1. Safety is no accident. ASTRO website. https://www.astro.org/Patient-Care-and-
Research/Patient-Safety/Safety-is-no-Accident. March 2019. Accessed on October
23, 2022.
2. Target safely. ASTRO website.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Target-Safely. 2010.
Accessed on October 23, 2022.
3. RO-ILS radiation oncology incident learning system. ASTRO website.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS. Accessed
on October 23, 2002.
4. Klein E, Dryzmala R, Purdy J, et al. Errors in radiation oncology: a study in pathways
and dosimetric impact. J Appl Clin Med Phys. 2005;6(3):81-94. http://doi:
10.1120/jacmp.v6i3.2105d