Herman1

Amy L. Herman

ROILS Incident Assignment

September 25, 2018

When it comes to treating with radiation you cannot be too careful. Safety should be the

priority of every radiation therapist, medical dosimetrist, medical physicist and radiation

oncologist. This is not a field that you can take back what you already delivered, so you want to

be sure that you have it right the first time. A situation occurred in a case where 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 the clinic after the 9th 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.1

Many contributing factors occurred that led to this error before the physician figured out

the intention of his prescription was wrong. The major factor was the lack of communication

through a verbal order given by the radiation oncologist to the medical dosimetrist in the first

place. Systems that facilitate clear, unambiguous and efficient communication between all team

members are critical.2 The medical dosimetrist decided to complete the plan based upon what

they thought they heard was the radiation oncologist's intention. There was not a clearly written

order from the radiation oncologist to develop the plan from. Furthermore, the medical

dosimetrist entered the prescription into the electronic medical record for the patient. This is
 Herman2

another major safety factor. Under no circumstances should anyone other than the radiation

oncologist writes a prescription for a patient's treatment, even if they were given a verbal order.

A patient's prescription for a radiation treatment should be treated as any other medical

prescription ordered by a physician.

Another contributing factor that may have led to this error was no proper “time out”

procedure. In a “time out” procedure before the physician signs off on the plan, they would

compare the written prescription to the plan prescription. The dosimetrist and physician would

verify the correct daily dose, total dose, energy used, prescription point, filming modality, how

often the patient will be coming for treatment, and any other special factors in the patient's

treatment that should be noted.1 As part of the general QA guidelines the radiation oncologist is

also to review the dose fractionation techniques and dosimetric constraints with the dosimetrist

before he or she signs off on the plan.2

It is important to have a policy in place to prevent accidents like this from occurring. One

idea would be to standardize radiation prescriptions.1 The prescription should include the

patients name, account number, course name, plan name, total dose of plan, daily dose, fraction

number, energy used, anatomical site, method of delivery, treatment schedule or frequency,

prescription volume or point, and film guidance.1 There would be a policy put in place that only

a radiation oncologist would be able to fill out a prescription for a patient's radiation treatment.1

After the prescription is completed and signed off by the physician, the medical dosimetrist can

complete the plan. The policy should also state that no other health care worker should be

allowed to alter the prescription during the treatment. If the physician wishes to change

something within the period of the patient's treatment, they would have to edit the prescription
 Herman3

themselves. In the event the physician edits the prescription, the original intended prescription

should always still be viewable.

Another policy that should be implemented into this facility is a “time out” procedure.

The ACR strongly recommends a procedure put in place to be completed before the final plan is

signed off by the radiation oncologist.3 Once the medical dosimetrist has completed the plan,

they would pull up the document prescription filled out by the radiation oncologist. The

dosimetrist and the radiation oncologist would compare the plan to the prescription making sure

the plan is prescribed in the same manner that the radiation oncologist ordered. If everything

agrees then the radiation oncologist can sign off on the plan. This same procedure should carry

out to everyone that will be checking the patients' chart. When the physicist does their check,

they would again bring up the prescription and verify everything agrees as well. Finally, same

goes for the therapist before the patients first day of treatment. You can never be too careful

when it comes to patient safety. The more policies and procedures you have in place the less

room for error throughout your facility.

References:

1. American Society for Radiation Oncology. Radiation Oncology Incident Learning

System. Quarterly Data Reports Patient Safety Work Product. (Clarity PSO).

Website.https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Patient_Safety/RO-

ILS/Content_Pieces/2017Q3Report.pdf. Accessed September 2017.

 Herman4

2. Blumberg A, Burns A, Cagle S, Et al. Safety is No Accident, A Framework for Quality

Radiation Oncology and Care, (ASTRO) 2012.

3. American College of Radiology, Radiation Oncology Practice Accreditation Program

Requirements. Revised July 2018.