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Bianca Tester
September 29, 2018

ROILS System – Case #1

Although there are many QA checks/safety interlocks involved in the treatment of

radiation therapy, mistakes still occur. In 2005, one Florida hospital disclosed that 77 brain
cancer patients had been mistreated due to a linear accelerator being commissioned improperly,
and this was just one of the many examples mentioned in the New York Times article, trying to
highlight the inconsistency of regulation in medical radiation.1 In order to better track and
prevent future accidents from occurring, a program called Radiation Oncology Incident Learning
System (RO-ILS) was created for staff to input any misadministration or near-miss events.2 The
mission of RO-ILS is to provide a secure, web-based portal for facilities across the US to
document or view errors previously logged, so that other facilities may learn from their
mistakes.2 Since the creation of RO-ILS in 2014, more than 425 facilities have participated and
have logged numerous incidences/near-misses.2
The purpose of this paper is to discuss a specific RO-ILS case, where a dosimetrist took a
verbal order to produce a plan to 3600 cGy. The dosimetrist produced a plan for 180 cGy daily,
for 20 fractions, while the physician intended for the prescription to be 300 cGy daily, for 12
fractions. Although both fractionations deliver the same total dose of 3600 cGy, the therapeutic
effect is drastically different. The physician approved the plan, and didn’t see the patient until
the 9th fraction for a weekly visit, and was surprised at how little the tumor regressed, and that’s
when the physician realized that the prescription was incorrect.
There were many contributing factors that lead to this treatment error, I believe the
biggest mistake was for the dosimetrist to assume the patient was receiving a ‘standard’
fractionation. As an experienced radiation therapist, I still get nervous with verbal orders and
will ask for clarification until I’m absolutely sure I’m delivering what is asked. If I was the
dosimetrist, after hearing, ‘make a plan going to 3600 cGy,’ I would have immediately asked the
physician what type of fractionation was needed. By just taking an extra minute to stop and ask
for clarification, this error would have been prevented. On the flip side, the physician shouldn’t
have assumed the dosimetrist could read their mind and know exactly what they meant by 3600
cGy, and they could have elaborated by saying, “I want 300 cGy for 12 fractions, for a total of
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3600 cGy.” If the physician would have been up front with their thought process, again the error
would have been prevented. The underlaying issue for this RO-ILS case is communication, or
lack thereof.
As treatment techniques become more complex, like with VMAT or forward planning,
the likelihood of errors increases, because nothing is straightforward anymore – especially how
prescriptions are written. As a dosimetry student, I’ve done a clinical rotation for only 9 months
and have witnessed firsthand near-misses not only by the dosimetrists, but also the physicians,
physics, and radiation therapists. One specific example that comes to mind is: I was planning a
head and neck patient that had two separate PTV’s drawn, one for 6000 cGy, and the other for
5400 cGy. Normally how these are drawn, the larger treatment volume receives the lower dose,
while the area where the tumor was surgically removed receives the higher dose. For this
specific case, the PTV’s were drawn opposite of what I just explained, so the larger volume
received the higher dose, while the smaller volume received the lesser dose. The physician had
drawn the volumes at night, after everyone had left the clinic, was off the next day, and left no
note to clarify the volumes he drew. When I came in the next morning and started evaluating the
volumes, I immediately asked my preceptors to look at the volumes drawn because they
appeared to be labeled incorrectly (which does happen more often than not, unfortunately). Both
dosimetrists agreed that the physician was probably in a hurry and accidently mislabeled the
PTV’s, so I was to re-label the PTV’s and proceed with planning. When the physician came back
the next day, before I could pull the plan up for him to evaluate, he made a comment about trying
a new technique that he read in a journal, where they gave the higher dose to the larger volume,
while the GTV basically received a lesser dose. After he made this comment, I relayed the
message to my preceptors to let them know I think we accidentally mis-planned the patient,
because the physician did in fact have the volumes labeled the way he wanted it treated (this was
the very first plan he was trying this new technique on). The preceptors and I did more
investigative work by reading the prescription note more thoroughly, as well as the consult note,
and came up with discrepancies, so we knew it was time to ask the physician for clarification.
Once we fully understood what was being asked, we were able to re-do the plan and have it
approved by the physician, and again specifically point out which PTV was to receive which
dose. The dosimetrists went back and edited the prescription and note to ensure all
documentation correctly reflected the physician’s treatment objectives. I felt this was a great
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learning experience to showcase it doesn’t matter how many years of experience you have, there
is always a chance to make mistakes, so if there are ever any questions about how the physician
wants the patient treated, it’s best to just stop what you’re doing and ask for clarification. In the
end, not only does this save time, but it could also prevent a patient from being mistreated.
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References

1. Bogdanich W. Radiation offers new cures, and ways to do harm. New York Times.
January 23, 2010. https://www.nytimes.com/2010/01/24/health/24radiation.html?
mcubz=0. Accessed September 29, 2018.
2. ASTRO. ROILS. ASTRO website. https://www.astro.org/Patient-Care-and-
Research/Patient-Safety/RO-ILS. Accessed September 29, 2018.