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Jessica Ezelle

Safety Essay

October 8, 2017

The medical dosimetrist has a vital role in the radiation oncology process. They receive
the simulation images, mark the isocenter created in the simulator, and fuse any images asked for
by the radiation oncologist and contour most of the critical structures in the area of treatment.
Once the radiation oncologist has defined their target volumes and completed their planning
directive, it is up to the medical dosimetrist to create the most optimal treatment plan for the
patient that gives the planning target volume (PTV) the best coverage while sparing the organs at
risk (OR) to the best of their ability and most importantly meeting the required constraints of the
planning directive.

In order to ensure safety in every day practices a medical dosimetrist must first and
foremost, always ensure they are conversing in unambiguous and efficient communication with
all the radiation oncology team members.1,2 Any grey area in communication can lead to error
in patient treatment. The medical dosimetrist must be sure they clearly understand the
prescription the radiation oncologist is prescribing the patient and where he or she is prescribing
it to. This alone could cause an underdose or overdose to a patient if a medical dosimetrist were
to misunderstand the prescribed treatment or even a misadministration if the dosimetrist planned
to the wrong contoured volume altogether.

Reporting any errors or near misses the medical dosimetrist knows about quickly and
efficiently can lead to error prevention or minimize possible error.1 If the medical dosimetrist
does not give all the information or is unclear in the information given, the error may still occur
or may not be properly addressed, causing harm. Open communication is key in radiation
oncology.

Properly placing and defining beams is another way to limit errors.1,2 A beam labeled
RT SCV G 345 is much more descriptive and helpful in patient set-up than a beam labeled
LAO. As a therapist you would be able to look at that beam and know you should be under the
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supraclavicular prescription and your gantry should be at an angle of 350 degrees. If one or both
of those are not matching this should alarm the therapist that something is not correct with this
patients plan and therefore, they should not treat it. Little details in patient charts such as this
add extra verifications that can help limit or eliminate errors.

Having set standards within the radiation oncology department as a whole helps to
increase safety and even more so in the medical dosimetry department.1 If there is a standard
guideline that everyone follows in their planning process, mistakes are more easily found. If
plans are uploaded into the patient chart in a certain order, it is more obvious when a document is
missing or if a second check has not been performed on a patient. If the actual planning process
is completed in a standardized process, medical dosimetrists are less likely to miss steps in
planning such as changing the dose grid, or IMRT parameters that may reset with every patient,
and could cause a difference in dose calculation if not set to the preferred parameters. With these
standards set policies and procedures can be created. This allows for documents to be created
that medical dosimetrists can follow, allowing them to focus on the task at hand, reducing
distractions.1 Therefore, increasing safety by reducing error.

Medical dosimetrists can also increase the safety of their plans by being self-mindful of
their own actions. Actions such as verifying contoured structures behind ones self increases the
likelihood of finding slices that may have missed being contoured or may find areas over or
under contoured that need to be fixed.1,2 Any errors in contouring, PTV or OR, can misrepresent
the dose the structure is receiving and cause harm to patients. For instance, if an OR is over
contoured on the plans dose volume histogram (DVH), the OR may show that it is with in the
tolerance allowed by the planning directive. However, in reality the OR is only meeting the
constraint due to the fact that it has been contoured larger than it actually is, if the contour were
to be fixed and the total volume reduced the dose allowed to structure volume ratio may not meet
planning directive tolerance.

Once a medical dosimetrist has reviewed their own work it should be standard that there
be a peer-review of their work.1 In most clinics this is performed by a medical physicist. A peer-
review allows for a second set of eyes to look over the medical dosimetrists work and ensure that
their monitor units were properly computed, their prescription matches what the radiation
oncologist prescribed for the patient. This also allows for someone to ensure that the medical
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dosimetrist sent the plan to the proper machine. It is crucial for the medical dosimetrist to submit
their plan for a peer-review. It is easy to oversee ones own mistakes, a peer-review provides
another verification that everything calculated in the patients plan is as it should be and limits
possibilities of mistreating patients.

One other way medical dosimetrists can maintain safety in their daily routine is quality
assurance (QA).1 Whether this QA be of the treatment planning system (TPS) to ensure that
nothing has changed leading to major differences in plan calculations, or running intensity
modulated radiation therapy (IMRT) QA on the treatment machine. IMRT QA on the treatment
machine helps to ensure that everything the medical dosimetrist planned in the TPS is able to be
successfully delivered on the actual treatment machine. Just because a medical dosimetrist
achieved an optimal plan on paper does not always mean it will translate as beautifully on the
treatment machine. The medical dosimetrist needs to run the IMRT QA to verify that the patient
will in fact receive the dose he or she planned. Without this verification, there is the possibility
of delivering an incorrect and harmful treatment to a patient.

Radiation and patient safety is something all radiation oncology team members must be
mindful of at all times. Medical dosimetrists have to ensure the proper contouring of their
structures, the most accurate calculation of dose and the proper transfer of the treatment plan to
the proper treatment machine. The biggest key to all of a medical dosimetrists safety measures
being fulfilled is unambiguous communication between all radiation oncology team members,
whether it be oral or written communication. There has to be only one was to interpret the
information being passed along to be sure that safety is maintained throughout the radiation
oncology department.
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References

1. American Society for Radiation Oncology. Safety is No Accident a Framework for

Quality Radiaiton Oncology and Care. ASTRO. 2012.
2. Marks L, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation
oncology. Practical Radiat Onc. 2011;1(1):2-14.
http://dx.doi.org/10.1016.j.prro.2010.10.001.