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Lauren Jankowski
Professional Issues in Medical Dosimetry
October 20, 2022
ROILS
The field of Radiation Oncology is ever evolving and consistently becoming more
complex as its aims to provide better outcomes for patients with fewer side effects. It is
important that quality assurance measures stay updated to ensure accurate and efficient treatment
for patients while minimizing potential risks. Since a New York Times article appeared in 2010
showcasing the lethal effects of radiation, the American Society for Radiation Oncology
(ASTRO) and the American Association of Physicists in Medicine (AAPM) joined together to
launch a new set of standards and implement the Radiation Oncology Incident Learning System
(ROILS) in 2014.1,2 Its mission was to facilitate safe quality care to patients by providing a space
for facilities to report incidents, near misses, and unsafe conditions and learn ways to improve so
these incidents do not happen again. In addition, facilities receive legal protection afforded by
the Patient Safety and Quality Improvement Act, can attend periodic educational events, and
gain access to multiple analysis tools.2
One case presented in the ROILS system involved a treatment field treated twice within a
single day. A new patient was scheduled for treatment and upon completion of the first fraction,
the treatment console notified the therapists first “Session Complete,” and then notified them that
the patient would receive “underdose” for the day after selecting “yes.” The therapists quickly
asked the patient to wait and called the dosimetrist. Both parties looked for verification and could
not find any other than the dose written in black monitor units (Mus) in the record and verify
system as opposed to red which would indicate it had not been treated. The dosimetrist opted to
add another field for treatment that day. After finishing the patient’s treatment for the day, the
therapists notified physics who contacted the vendor to pull the logs. The logs confirmed that the
last field had been delivered twice that day.
One of the most important factors leading to this incident was a lack of communication
across the entire treatment team. According to “Safety is No Accident”,3 the majority of radiation
treatments use standard operating procedures (SOPs) describing treatment approach. When
treatment does not go as intended, it is recommended that a huddle occur between all team
members including but not limited to the therapists, dosimetrists, physicists, and physician.
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While a huddle did occur between the therapists and dosimetrist, physics and the physician were
not involved. A question over whether radiation was given should be a “hard stop” before adding
in an additional field to treat and all team members should agree on a course of action. In
addition, the conflicting information between the record and verify system and the treatment unit
should have prompted further investigation. This department could benefit from procedures in
place on who to contact when problems arise outside of the SOPs.4 Similar incidents occur with
power outages during beam delivery. Many treatment units are equipped with a MU backup
counter that records the number of MUs delivered of the last beam in the event of treatment
interruption. If this was available, the treatment team should have first verified this number and
compared it to the treatment field in question. Furthermore, the course of action should be to
contact physics and the dosimetrist with one therapist caring for the patient while the other, the
treatment “driver,” taking note of the monitor units delivered on the counter and seeing how it
compared to the field delivered.
The second contributing factor leading to this incident was the medical dosimetrist
stepping beyond their qualified role and responsibilities. In section 2.1 in “Safety is No
Accident”3, the scope of practice for each team member should be defined by the department,
their professional organization, and local jurisdiction. In all instances, medical dosimetrists must
practice under the supervision of a qualified physician and qualified medical physicist. Normally,
machine troubleshooting issues fall under the scope of the medical physicist, or at a minimum
with consultation of a medical physicist. Again, policies and procedures should have been in
place defining roles, responsibilities, and expectations within this department.4
While surmised, a third possible cause to this incident could be distractions in the control
room during treatment delivery. As dictated by SOPs, the therapist delivering the treatment
should remain focused both on the patient and treatment console throughout the entire course of
treatment, noting fields delivered, clearance issues, and patient movements. In this case, simple
workflow changes and quite reminders of keeping distractions or questions at bay while
treatment is being delivered should cut down on potential incidents.
Clear scenario-based procedures have proven beneficial in mitigating unexpected events
in radiation oncology. Regardless of clinical roles, communication, and software malfunction,
treatment team members should take a step back and reevaluate before delivering “additional”
radiation to a patient. If there is ever a question, it is best to have more information rather than
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less. In a situation like this, there is no harm in delivering less dose and making up for it
throughout treatment rather than overdosing the patient. Many incident learning systems
reference the Swiss cheese model as to why incidents happen and near misses are caught.
Multiple levels of verification are necessary for each and every treatment in order to provide safe
and efficient treatment to our patients.4
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References
1. Radiation therapy's harmful side. The New York Times.
https://www.nytimes.com/2010/01/27/opinion/27wed3.html. Published January 27, 2010.
Accessed October 17, 2022.
2. RO-ILS. ASTRO Web site. https://www.astro.org/Patient-Care-and-Research/Patient-
Safety/RO-ILS/RO-ILS-Background. 2022. Accessed October 17, 2022.
3. Safety is No Accident: A Framework for Quality Radiation Oncology Care. ASTRO
Website. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Safety-is-no-
Accident. March 2019. Accessed October 17, 2022.
4. Hendee WR, Herman MG. Improving patient safety in radiation oncology. Medical Physics.
2010;38(1):78-82. https://doi.org/10.1118/1.3522875