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Dan Frieling

ROILS Incident

9/26/18

In any healthcare setting, it is essential to have proper communication between medical

professionals. The patient’s safety and well-being must be of the utmost importance. However,
there are instances when accidents occur. The Radiation Oncology Incident Learning System
(ROILS) is a comprehensive solution for the documenting, tracking, analyzing, and trending of
patient incidents.1 In these moments the medical community must self-reflect to analyze what
went wrong and how to improve in the future. By doing so, policies can be put in place that
prevent similar errors from happening again.

Being a large institution, ROILS receives many incident reports each year. One
particularly distressing report arose in the fall of 2017. In this case, the radiation oncologist
intended to prescribe a treatment of 300 cGy a fraction over twelve fractions. This would result
in a total dose delivered of 3,600 cGy. However, the plan generated by the dosimetrist was 180
cGy per fraction over twenty fractions. The physician approved the plan without noting the
discrepancy between the intended and resulting prescriptions. Later, after nine treatments, the
physician noted the lack of expected tumor regression. This alarmed the physician and led to an
investigation as to why this was occurring. That is when the prescription error was found.

There is a lot to analyze in a case such as this one. First, it is prudent to discern what the
contributing factors were that led to the aforementioned error. One factor that jumps off the page
is the lack of clear communication between the physician and treatment planner. It’s difficult to
assess just what was said regarding the prescription. However, whatever was communicated
obviously wasn’t clear and consistent. Another factor could be the plan review process itself.
From the excerpt provided by ROILS, it is difficult to assess just how the plan was reviewed by
the physician and dosimetrist. It is safe to assume, though, that the analysis of the plan was
inadequate. The physician should have noticed the prescription error at this point and made the
appropriate corrections before treatment commenced.
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Given the contributing factors noted earlier, the question remains as to what can be done
to avoid similar errors in the future. The simplest action would be to standardize prescriptions. If
the physician is continually changing what he/she prescribes for similar treatments, there is room
for confusion with the treatment planner. Each method of treatment should have a standard
prescription that accompanies it. If this is changes, for whatever reason, there should be clear
written communication between the physician and dosimetrist explaining the difference.

Another recommendation would be to regulate the prescription process. This includes

who writes the prescription and when they would do so. Given that the physician ultimately
makes the final decision on the treatment plan, it would make since that they write the
prescription. It would be beneficial to the dosimetrist, and all involved, if this were done as soon
as possible. At the time of treatment plan review, the prescription should again be checked by
both the dosimetrist and physician to ensure accuracy. If these suggestions are followed, there
would be a consistent thread throughout the treatment planning process. The physician and
dosimetrist would be in sync, which would help prevent mistakes.

In the article, “Safety is No Accident”, the authors outline the steps that must be taken in
order to ensure a safe and mistake free treatment for patients. They state, “Each facility must
have policies and procedures defining the roles of team members.”2 It is vital that every member
of the department understands their part in the radiation treatment process. This removes
confusion from the equation and allows the department to function at peak proficiency.

As has been mentioned earlier, there are many ways to ensure that a radiation oncology
department operates efficiently. When it comes to prescriptions, it is essential that they are
accurate and follow what the physician desires. This requires clear communication and
consistent regulation over the prescription writing process. If this is done, departments can be
assured that patients are receiving the correct prescribed dose. In the end, the patient’s safety and
well-being is the most important factor.
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References:

1. Radiation Oncology Incidence Learning System. Quarterly Report Patient Safety Work
Product: Q3 2017.
https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Patient_Safety/RO-
ILS/Content_Pieces/2017Q3Report.pdf. Accessed: 9/25/18.
2. Blumberg A, Burns R, Cagle S, et al. Safety is No Accident. American Society for
Radiation Oncology (ASTRO). 2012: 11-24.