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  Kyle Garafolo DOS 518  –   Professional Issues October 6, 2019 RO-ILS Case Discussion Case one: Planner wrote prescription for the physician to sign “ The Dosimetrist took a verbal order to generate a plan to 3600 cGy and entered the  prescription into the electronic medical record. The physician's intended prescription was 300 cGy x 12 fractions = 3600 cGy but the plan was generated for 180 cGy x 20 fractions = 3600 cGy. The plan was approved by the physician and exported to the treatment unit. During the second week of radiation therapy the physician saw the patient in the clinic after the 9th fraction was given to the patient. The physician was surprised by the lack of tumor regression. Upon checking the electronic medical record the physician noted that the daily dose was not in multiples of 300 cGy. ”  The Radiation Oncology Incident Learning System (RO-ILS) case log previously described details an unfortunate situation where numerous errors led to the improper treatment of a patient. While the problem in this incident simply appears to be an incorrect radiation  prescription fractionation, the true areas of concern are much more profound. Several of the likely contributing factors that led to this incident include: miscommunication of the verbal order details, plan approval by the physician without a thorough review of the treatment plan details, and lack of plan/written prescription review by the medical dosimetrist, medical physicist, and radiation therapist during pre-treatment and weekly chart checks. Based on the provided information, there were multiple opportunities for this error to have been caught prior to reaching the patient. Because this event was entered into the RO-ILS, this information can be used for shared learning in order to improve quality and patient safety in radiation oncology departments in the future. The RO-ILS was formed by the American Society for Radiation Oncology (ASTRO) and the American Association of Physicists in Medicine (AAPM) in 2011 as a means to create a nationwide radiation oncology incident learning system. 1 The intended purpose of this system is to establish a culture of safety in radiation oncology institutions by promoting safety and high quality patient care through a non-punitive and shared learning reporting system. 1  By raising  awareness of potential risks, near misses, and other safety events on a national level, radiation oncology as a whole can hopefully become a safer field of medicine. In reviewing the contributing factors that led to this event, several recommendations could be made that may prevent this type of error from happening in the future. For the first contributing factor, miscommunication of the verbal order, a standardized process for verbal receipt of the radiation prescription from the physician could be developed. Standardization is a common method for minimizing errors and should be adopted into standard practice. 2 Key elements of the radiation prescription to be discussed should include: treatment site, method of delivery, dose per fraction (in cGy), total number of fractions, and total dose (in cGy). Incorrect assumptions by both the medical dosimetrist and radiation oncologist led to the improper treatment fractionation for the patient. By the time the physician entered prescription details into the patient’s electronic medical record (EMR), the medical dosimetrist should have noticed the variance in treatment fractionation prior to documentation and made the correction. Standardization of the verbal order process would be the first recommendation for preventing this type of error from reaching future patients. The second contributing factor associated in this incident involved the inadequate plan approval by the radiation oncologist. Amongst the many responsibilities of the radiation oncologist, they are also tasked with formally approving the radiation treatment plan. The treatment plan approval process should include verification that the plan meets the intended clinical requirements through a review of the prescription, contoured OAR, isodose distributions within the patient, as well as quantitative analysis of targets and organs-at-risk (OAR) on the dose-volume histogram (DVH). 2 Had the physician in this case properly reviewed all the aforementioned items, the incorrect dose fractionation should have been caught much sooner than it did. Aside from the physician’s complete oversight of the patient’s treatment course, checks and approvals should be completed by other radiation oncology staff. 2  The third contributing factor that led to the improper treatment for this patient involved the lack of treatment  plan/prescription review by the medical dosimetrist, medical physicist, and radiation therapist during pre-treatment and weekly chart checks. Checklists should be incorporated as part of a quality control and treatment delivery process to help reduce the likeliness of errors in radiation oncology institutions. 3  Had checklists been incorporated into the organization’s standard   practice, the likelihood of the fractionation error bypassing the medical dosimetrist ’s  plan documentation, the medical physicist’s pre -treatment and weekly chart checks, as well as the radiation therapist’s pre -treatment and weekly chart checks could be presumed to be extremely low. Additionally, peer-review during weekly chart rounds could have been useful in catching errors such as the one described. By having multiple staff members verify treatment plan details  prior to and during treatment, errors are less likely to reach the patient and cause harm. The RO-ILS case log described was potentially the result of not one simple fractionation error, but by the lapse of a culture of safety within this radiation oncology department. Several  processes could have been utilized to promote safety and a high level of patient care, likely catching the treatment error long before the patient’s 9 th  fraction. Through the use of national incident learning systems such as RO-ILS, safety will remain at the forefront of radiation oncology institutions’ and hopefully reduce future errors from reaching the patient.  References 1.   Hoopes DJ, Dicker AP, Eads NL, et al. RO-ILS: Radiation Oncology Incidnet Learning System: A report from the first year of experience.  Pract Radiat Oncol.  2015;5(5)312-318. https://doi.org/10.1016/j.prro.2015.06.009 2.   American Society for Radiation Oncology (ASTRO). Safety is no accident: A framework  for quality radiation oncology and care. 2019. Accessed October 6, 2019. 3.   Hendee W, Herman M. Improving patient safety in radiation oncology.  Med Phys . 2011;38(1)78-82. https://doi.org/10.1118/1.3522875 
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