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Patrick Sheil
Safety Paper
October 6th, 2017

Technology in the field of radiation oncology is rapidly advancing. With the ever-
evolving advanced technologies becoming implemented in more clinics, it is imperative
that all members of the radiation oncology staff are properly trained and knowledgeable
of updates. The advancement in computer technology specifically has placed medical
dosimetrists in the forefront of many new processes. Medical dosimetrists are tasked with
creating complex treatment plans while staying up-to-date on the relevant treatment
machines, equipment, and software.
Medical dosimetrists have various duties to perform on a regular basis. They are
responsible for assisting with simulations and tumor localization. When images are sent
from simulation, the dosimetrist is then tasked with image registration (CT, MRI, PET)
and identifying and accurately contouring all organs at risk (OR). After communicating
with the physician and receiving target volumes, the dosimetrist must then design a
treatment plan with optimal beam geometry and beam modifying devices to the
prescribed dose while sparing all critical organs in agreement with the physicians
constraints. Once treatment plans have been verified and approved by appropriate
members, the dosimetrist must then properly document all appropriate information in the
record and verify system and handle the billing. If the dosimetrist makes a misstep in any
of the duties mentioned then potential harm could occur to a patient. Due to the fact that
the dosimetrist has such a critical role in the care of patients, it is imperative that daily
safety procedures are implemented to ensure mistakes are not overlooked and proper care
is given.
One example of how dosimetrists can integrate safety into daily practice is
through clear communication with all team members.1 A radiation oncology team
consists of multiple different medical professionals, each with their own respective duties
and over-seeing multiple patients a day. This busy work environment and multiple hand-
offs from one member to the other increases the chances of miscommunication and
errors. The plan prescription, blocking, field size and many other aspects that the
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dosimetrist enters into the computer comes directly from the physician. If there is any
ambiguity in this process then that can lead to a domino effect which can result in patient
harm or a treatment plan that cannot be used.
This communication aspect plays a role in workflow and efficiency as well. It is
important that all team members on the same page when it comes to each patient.
Dosimetrists must be vocal to the therapists and physicians about adequate time needed
for each patient that is to start treatment. If the turn around time for a plan to be done is
too soon then the dosimetrist will be more prone to error and make a less than ideal plan.
By having constant streams of communication, a dosimetrist can allow a realistic
schedule for themselves and avoid/minimize rushing to get a plan done and risk errors.
A second example of how dosimetrists can integrate safety into daily practice is
through peer review. Dosimetrists typically work independently on multiple plans at once
and therefore solely their eyes serve as a check to ensure there are no errors. According to
Radiation Oncology Incident Learning System (ROILS) comprehensive report, it found
that errors are most frequently identified during treatment planning.2 The top five most
detected errors by dosimetrists are the following (in order): billing, setup notes,
contouring, prescription issue, and tolerance table. By implementing
prospective/retrospective peer review, it allows a cross-check from a another qualified
individuals perspective that may help eliminate these errors that are overseen. These
potential saves are critical to workflow because it could save time for re-planning/quality
assurance purposes or from postponing a patients start date.
Another example of how dosimetrists can integrate safety into daily practice is
through checklists and standard processes.3 Dosimetrists could implement a checklist that
they must review before showing the physician their final plan for review. This checklist
could include the following: review prescription, patient positioning, fields sizes,
gantry/collimator angles, beam energy, reference point location, isocenter placement, and
beam modifying devices. This checklist will allow a comprehensive self-check that can
reduce potential errors and mistakes before the physician does his or her own self
evaluation of the plan.
The implementation of standard processes could also play a huge factor in
integrating safety. One example could be incorporating beam energy, site-specific
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nomenclature, or unique beam modifiers in the field names for therapists. For example, a
left breast being treated with tangential beams using beam energy of 6MV and 0.3cm
bolus, the field name would be LMed Tang Breast 6X 0.3cm Bolus. This standard
nomenclature can also be implemented in the naming of structures. For example, at
Northwestern Medicine Cancer Center-Delnor, all PTVs have a pre-set name with the
volume site and prescription dose incorporated (i.e. PTV_LLump_XXXX,
PTV_LLumpBst_XXXX, etc). The extra effort to implement these standards can
potentially help other staff/dosimetrists easily review plans for future references and help
prevent therapists from forgetting to incorporate bolus or treating the wrong site.
Medical dosimetrists play a significant role in the treatment process of every
single patient that comes through the clinic. It is imperative that all dosimetrists routinely
perform all of the mentioned daily safety practices. It is very easy for a dosimetrist to get
caught up in multi-tasking with numerous plans and have an error occur along the way. It
is also hard to gauge if an error occurs if the dose volume histogram (DVH) shows an
ideal plan with all constraints met. Just because a plan passes the DVH eye test does not
mean that it will pass the necessary quality assurance. It is important for dosimetrist to be
cognizant of all aspects that require second checks and not be afraid to reach out to peers
for double checks and clarify information that is ambiguous. Proper communication
between dosimetrists and other team members play a critical role in sustaining safety.
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References:
1. American Society for Radiation Oncology. Safety Is No Accident: A Framework
for Quality Radiation Oncology and Care.
https://www.astro.org/uploadedFiles/Main_Site/Clinical_Practice/Patient_Safety/
Blue_Book/SafetyisnoAccident.pdf. Accessed October 4, 2017.

2. Foster R, Bright M, Heinzerling J, et al. Implementation and Analysis of a

Prospective Dosimetrist Peer Review. International Journal of Radiation
Oncology. https://libweb.uwlax.edu:2289/10.1016/j.ijrobp.2017.06.1925.
Accessed October 6, 2017.

3. Adams R, Marks L, Pawlicki T, et al. The New Raidation Therapy Clinical

Practice: The Emerging Role of Clinical Peer Review for Radiation Therapists
and Medical Dosimetrists. American Association of Medical Dosimetry.
https://libweb.uwlax.edu:2289/10.1016/j.meddos.2010.09.002. Accessed October
6, 2017.