Ryan Salem

Professional Issues/ROILS incident

Due: September 30th, 2018
Treatment Field Treated Twice in One Day

In a radiation oncology incident, a patient had a single treatment field treated twice in one
day. On a patient’s first day of treatment, the patient was treated, and the therapists selected
“yes” when the treatment console prompted them with a “session complete” message. A
notification was given by the treatment console that the patient would receive an “underdose” for
the day. The therapists tracked down the patient in the dressing room and asked him to wait
while they contacted dosimetry. Between both the therapists and the dosimetrist, they could not
find a record of a certain field being treated that day in their computers. In the record and verify
system, it was indicated that he field was treated. Following this, the dosimetrist re-added the
field for the therapists to treat, so they got the patient back in the room and delivered the new
field B2. Following treatment, physics was contacted about what happened. Physics contacted
the vendor of the record and verify system to check the log files of the treatment. Both the record
and verify system and the vendor logs confirmed that the B2 field had been treated twice.

In this incident, there were a number of steps that led to the incorrect double treatment of
field B2, and some ways in which it could have been avoided. First and foremost, there was
some sort of computer error where the treatment console prompted the therapists that the
patient’s treatment was incomplete, when in all actuality it was treated properly. I believe the
therapists took the correct step in asking the patient to wait while they checked to ensure he or
she received proper treatment. After calling dosimetry, neither the therapists or dosimetrist was
able to confirm that the treatment plan was completely delivered, while the record and verify
system indicated that the patient received the correct dose for the day. At this point, physics
should have been contacted as there was no way to confirm one way or the other that the
treatment was accurately delivered. The dosimetrist, with conflicting indications of the dose
delivered that day, took initiative in the situation and decided to create a new field to be treated.
Following the retreatment, physics was finally contacted and took the correct steps in contacting
the vendors about what happened. It was confirmed that the treatment console, the therapist’s
computers, and the dosimetrist’s computers were wrong, and the record and verify system was
correct in the recording of the patients first treatment.

I believe the clinical site would be able to incorporate a process or policy to prevent this
sort of event from happening again fairly easily. First and foremost, when the treatment and
planning computers do not show the same result as the record and verify system in place, physics
should immediately be contacted not only after the treatment the error occurs, but also before any
more treatments are completed. This would prevent an event like this, or even one much worse
where multiple patients could be affected, from happening entirely. Another way that this action
could have been prevented is to not give dosimetry the power to create new treatment fields
without either physicist or oncologist permission. In a different situation where both the
treatment console and the record and verify do not confirm a dose delivery that the therapists
know they gave, physics and an oncologist should certainly be notified before too much or too
little treatment is ultimately delivered to the patient.

As stated in ASTRO’s article Safety is no Accident, it is emphasized that while providers

such as therapists and dosimetrists are responsible for the management of radiation treatment
delivery, their efforts fail in comparison to the comprehensive management of the radiation
treatment for which the radiation oncologist is solely responsible.1 Errors and “near-misses” are
rarely attributed to the physician when compared to performance and processes within a
department and communication issues between staff under the oncologist.2 When the physician is
directly involved in issues, the chance for an error goes down significantly.2 The radiation
therapists and dosimetrist involved in this incident went too far in assessing the situation and did
not allow the proper staff to make the crucial decision on what to do next following the treatment
console and record and verify discrepancy. An essential characteristic of a successful radiation
oncology department is having an error-free environment.1 Although mistakes do happen, simply
creating a culture where they are avoided as much as possible by diligence of all who are
involved leaves a small window for error on its own. Having the correct procedures and policies
in the event of unplanned circumstances is another key way to reduce mistakes in a medical care
facility. The implementation of electronic safety checklists is a simple way to reduce errors in
radiation oncology.2 In the incident described above, the error was certainly avoidable, and it did
not seem the department had enough policy in place, or competent enough staff to make the
correct decision when treatment errors occur.

References

1. Blumberg A, Burns A, Cagle, S. Safety is No Accident. [ASTRO]. July 2012. Accessed

September 30, 2018.
2. Greenwalt, JC, Mittauer K, Liu C, et al. Reducing Errors in Radiation Treatment Through
the Implementation of Electronic Safety Checklists. Int J Radiat Oncol Biol Phys.
2014;90(1):S128-S129