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Beverly Meyer
DOS 518 Professional Issues
October 7, 2017
Safety Essay
A medical dosimetrist is an integral part of the radiation oncology department, albeit
somewhat hidden to the layman. According to the American Association of Medical
Dosimetrists (AAMD),1 a medical dosimetrist has the knowledge and education to generate a
radiation plan along with the dose distributions and calculations while collaborating with the
medical physicist and the radiation oncologist. They also have a general knowledge of the
workings of not only the linear accelerators, but also the brachytherapy equipment. The
medical dosimetrist is the designer of the treatment plan which will deliver the prescribed
dose written by the radiation oncologist to a planned tumor volume (PTV) defined by the
doctor. While designing the plan, the medical dosimetrist takes much into consideration,
including the dose limiting structures or organs at risk (OR). The treatment plans are created
from CT scans which can be used alone or fused with other imaging studies, such as MRI or
PET scans.
Additionally, medical dosimetrists may be utilized in CT simulation as an assistant to the
radiation therapists to ensure the proper immobilization devices or patient positioning is used
to create the best plan to carry out the doctors prescription while limited dose to the OR.1
Medical dosimetrists are sometimes involved in daily, monthly, or annual quality assurance
(QA) tests on the machines, including linear accelerators, brachytherapy, or CT scanners.
Assisting the medical physicist is within the scope of practice of a medical dosimetrist also by
lending support in radiation protection or radiation measurements. Medical dosimetrists often
are called upon to mentor radiation oncology residents, dosimetry and radiation therapy
students. The role of the medical dosimetrist in a radiation oncology department is very
important and doesnt end there. We are also involved in patient safety to a staggering
degree, and just two weeks ago I understood this more intimately.
Our radiation oncology department has grown rapidly over the last 5 years. And with this
growth has come numerous changes: a new building, the addition of new high tech
equipment, as well as new staff including new doctors and nurses. Our department has grown
from a small community radiation oncology department where the radiation therapists acted
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as nurses, front desk staff and social workers, to a full-blown cancer institute with several
floors servicing many more patients from around the region. This rapid growth has led to
inefficient processes, little time to create policies and procedures, and staff frustration.2
Switching from paper charts to electronic medical records (EMR) has been painfully slow.
The radiation therapists readily took to EMR but the radiation oncologists have been reluctant
to change. Consult notes are rarely dictated in time for the simulation, and they are never
placed in the electronic chart. In essence, our electronic charts are merely dose calculators
and do not mirror the paper charts. The paper charts are kept in a chart room by the nurses
station for quick access for themselves and the doctors. The tradition of paper charts must be
reassessed in order for the practice to evolve and change with the rapidly changing field of
modern radiation therapy.2 In addition, our doctors routinely add-on patients to the simulation
schedule when there are no open slots. This results in a rushed and excessive workload,
which can lead to errors.
The radiation oncology department where I work and participate in clinicals just
experienced a medical event where the wrong lung was treated in a patient. Luckily, the
patient was his own advocate and spoke up, questioning which lung was being treated after
only the second fraction. In my 11 years as a radiation therapist, I have never experienced
anything like this. I forgot to put bolus on a chest wall once, and I immediately informed the
doctor, the physicist and the dosimetrist. I have never forgotten to place bolus since as I was
completely changed after that event. The mistreatment that occurred two weeks ago has had a
devastating effect on the whole department. If something good can come of this, it is that we
will change our current behavior and adopt the American Society of Radiation Oncologys
(ASTRO) framework for patient safety.2
A medical dosimetrist can integrate safety into their daily process in many ways. In
regards to the recent incident at my facility, I see two ways specifically that would have been
advantageous and possibly could have prevented the mistreatment. First, the dosimetrist
should always compare the consult note and the pathology report with the PTV. In this
specific case, neither the consult note nor the pathology report was contained in the patient
chart. This should be a hard stop, but we have been rushed through these processes so many
times by the physician, that it has unfortunately become a non-event. The physician in this
specific case drew the PTV on the left lung, instead of the right lung. An area of activity did
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show on the PET scan, but it had been deemed scar tissue on the pathology. If the consult
note and/or pathology report had been readily available, I believe this would not have
happened, or at the very least a dosimetrist would have caught the error when confirming the
PTV.
The other way medical dosimetrists can integrate safety into their milieu is to participate
in peer review. As radiation oncologists should have peer review for target delineations,
medical dosimetrists should also be involved with peer review, which is essential to safe
delivery of radiation.2 Being new to the field, I certainly would value the subjectivity of a
peers review on my plans. Once I graduate from the student role, I would like to campaign
for peer review of plans. As it is now, the medical dosimetrists rarely get to view how the
other dosimetrists plan on a daily basis. Valuable information can be shared and learned
through a peer review process. This is the second way I believe the aforementioned
mistreatment might have been stopped. Perhaps not in the dosimetry peer review since the
doctor was the one who drew the PTV on the incorrect lung, but in the interdisciplinary
review. Hopefully the team would have noticed the discrepancy between the diagnostic
images, pathology and contoured PTV.
It is extremely important for a department to foster a just culture; one where no one
person is blamed, rather, the process is reviewed and changed as a result. Our department has
gone through training called TeamSTEPPS, which is a curriculum based on strategies used to
enhance patient safety.3 The goal is to create a blameless culture where vital lessons can be
learned from errors and near misses. It has been proven that near misses and error reporting
has important impact on process improvement.4 The collection of electronic data over time is
crucial to analyzing data and implementing patient safety improvement measures especially
those dedicated to radiation events.
It has become painfully evident to me as a medical dosimetrist that I must integrate safety
into my daily practice. If it werent for the people who report near misses, medical events and
misadministrations, some errors would never be discussed. As the culture shifts to a more
blameless one, people are more willing to discuss errors so all may learn from mistakes. A
non-punitive culture will aid in communication by allowing professionals to report instances.
As our department is able to communicate about these instances openly and without blame,
the opportunity to brainstorm and discuss patient safety can become the cornerstone of the
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department. As I stated previously, I hope that change for the good is the result of this
regrettable event.
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References

1. What is a medical dosimetrist? American Association of Medical Dosimetrists.

https://www.medicaldosimetry.org/about/medical-dosimetrist/. Published 2017. Accessed
October 7, 2017.
2. Zietman AI, Palta JR, Steinberg ML, et al. Safety is no accident: a framework for quality
radiation oncology and care. Arlington, VA: ASTRO; 2012.
3. U.S. Dept. of Health and Human Services. Agency for Healthcare Research and Quality Web
site. Team strategies and tools to enhance performance and patient safety. Rockville, MD.
https://www.ahrq.gov/teamstepps/index.html. Accessed October 7, 2017.
4. Mutic S, Brame RS, Oddiraju S, et al. Event (error and near miss) reporting and learning
system for process improvement in radiation oncology. Med Phys. 2010;37(9):5027-5036.
http://dx.doi.org/10.1118/1.3471377