Ryann Edwards

DOS 518

ROILS

Case: Planner wrote prescription for the physician to sign

The dosimetrist took a verbal order to generate a plan to 3600 cGy and entered the
prescription into the electronic medical record. The physician’s intended prescription was 300
cGy x 12 fractions = 3600 cGy but the plan was generated for 180 cGy x 20 fractions = 3600
cGy. The plan was approved by the physician and exported to the treatment unit. During the
second week of radiation therapy the physician saw the patient in clinic after the 9 th fraction was
given to the patient. The physician was surprised by the lack of tumor regression. Upon checking
the electronic medical record, the physician noted that the daily dose was not in multiples of 300
cGy.

The error in this case could have easily been avoided. There are several contributing
factors to the mistreatment of the patient. The first factor is policy/procedures were not followed.
There are policies and procedures in place for this reason, both the physician and dosimetrist did
not follow the procedure properly. The second factor is poor communication. The physician
should have specified his wishes, and the dosimetrist should have asked for clarifications. There
was also a lack of communication from the entire radiation oncology team. The plan went
through several team members for approval without the mistake being caught.

The scope of practice for a qualified medical dosimetrist (QMD) is clearly defined by the
American Association of Medical Dosimetrists (AAMD).1 This includes acquisition of patient
data via computer generated data sets from medical imaging, assisting in image guidance,
assisting in treatment simulation process, generation of isodose distributions, and more.1
However, generating the radiation prescription is nowhere in the QMD scope of practice. The
Radiation Oncologist (RO) is a board-certified Doctor of Medicine who is licensed to practice
their medical specialty and who prescribes and/or utilizes radiological procedures for individuals
for the diagnosis or treatment of their ailment.1 It is the RO’s responsibility to generate the
prescription and ensure the prescription will treat the patient properly. The dosimetrist’s scope of
practice comes into play in avoiding the error stated above.
 The dosimetrist scope of practice and policies/procedures are in place for the safety of the
patient and the dosimetrist. The dosimetrist should avoid doing anything out of their scope of
practice and should always explicitly follow the policies/procedures that are in place by their
facility. In 192,477 errors reported, 16.6% of them were caused by procedures/protocols not
being followed.2 To avoid the error of treating to the correct prescription that was intended by the
physician the dosimetrist should have refused to take the verbal prescription and remind the RO
of the procedures in place. The dosimetrist should have waited for the written prescription to be
in before planning. The facility should have explicit written procedures to avoid moments such
as this. An example of procedures from a clinic would include the RO evaluating the patient,
determining the correct route of treatment, receiving informed consent from the patient, the
patient undergoing a CT simulation scan, the RO ensures the prescription is explicitly written in
the record and verify system, the RO, dosimetrist and physicist have a discussion about the
treatment planning process, the dosimetrist would proceed with planning, once done the RO
would approve the plan. Once approved the dosimetrist would export the plan and then it would
need to be approved by the physicist and radiation therapist before treating the patient. 3 The
communication of the radiation oncology team is crucial for properly and safely treating the
patients.

Communication is important for any team to succeed, especially for the radiation
oncology team. Each team member works closely with one another to ensure that patients are
being treated correctly and safely. The radiation oncology team relies on communication to
ensure the proper policies and procedures are followed. The error discussed above could have
been avoided if the team communicated properly with one another. Although the dosimetrist
should not take verbal orders from the physician, the dosimetrist should have asked for
clarification. The dosimetrist could have also referred to the physician’s note in the patient’s
chart for clarification. Beyond the simple communication mishap, the plan made it through
several members of the team before the wrong prescription was noticed. The physician should
have made sure the dosimetris was aware of the desired prescription, the dosimetrist should have
double checked the prescription with the physician, the physician should have double checked
the prescription before approving the plan, the physicist should have checked the prescription,
and the radiation therapist should have checked the prescription. They should have
communicated with each other to figure out the physician’s wishes prior to treating the patient.
The Radiation Oncology Incident Learning System (RO-ILS) is a free program that allows
facilities to contribute to patient safety data to a database.4 The program is tied to a patient safety
organization with a mission to facilitate safer and higher quality care in radiation oncology by
providing a mechanism for shared learning in a secure and non-punitive environment.4 The RO-
ILS program includes safety notices, case studies, themed reports, and aggregate data reports.4
The error discussed above was just one of many case studies included in the program. The error
could have been avoided with proper procedures being followed and proper communication.
 References

1. AAMD. Scope of practice of a medical dosimetrist. May 2023. Medicaldosimetry.org.

https://www.medicaldosimetry.org/about/scope-of-practice/. Accessed October 27, 2023.
2. Lenars, Nishele. Continuous Quality Improvement. [Softchalk]. La Crosse, WI. UW-L
Medical Dosimetry Program. 2019. Accessed October 27, 2023.
3. ASTRO. Safety is no accident a framework for quality radiation oncology and care. 2012.
American society for radiation oncology.
https://www.astro.org/uploadedFiles/Main_Site/Clinical_Practice/Patient_Safety/
Blue_Book/SafetyisnoAccident.pdf. Accessed October 27, 2023.
4. AAMD. RO-ILS: Radiation Oncology Incident Learning System. Medicaldosimetry.org.
https://www.medicaldosimetry.org/resources/quality-and-safety/. Accessed October 27,
2023.