1. QA Project #4
Deviation Review/Policy
Creation
Katie DeMeulemeester

2. Case
• SL3
• 06/03/11
• Time:
• Diagnosis: Left Mycosis Fungoides, unspecified site
• Primary site: left gluteal area
• Goal of treatment: curative
• Beam energy/modality: e08
• Ports: 313°
• Dose: Total: 3600 cGy Daily: 180 cGy x 20 fractions
• Fraction #: 13 of 17

3. History
• Female 10/20/1942
• A 68-year-old Caucasian female with a known diagnosis of a stage IV a refractory cutaneous T-cell
lymphoma. She has undergone a series of systemic therapies as above noted and well
summarized in previous notations made by Dr. Mark Kaminski as well as Dr. Jaiyesimi, which are
attached to this chart/consultation. Most recent treatment has been with Campath systemic
therapy under the guidance of Dr. Jaiyesimi. The response has been quite good except for a
persistent lesion within the left buttock region, with a maximum dimension of 2.5 cm. She has
had prior scalp irradiation delivered at the University of Michigan under the guidance of Dr.
Christine Tsien, which resulted in a quite durable response within the scalp which was irradiated.
Thus, based on this excellent prior response to the cutaneous lesions involving her scalp, I believe
a course of local field irradiation to the persistent left buttock lesion should respond equally well.
Pursuant to this, I have contacted our scheduling office to arrange for a simulation treatment
planning session. I believe that the modality of choice would be a direct en-face electron field
with relatively low energy, i.e., 6 or 8 MeV to a similar total dose as per previous scalp treatment,
i.e., 24 to 25 Gy.
• PAST MEDICAL HISTORY: She denies any major medical problems other than for that reported
in the History of Present Illness. Indeed, she denies any hypertension, diabetes mellitus, or other
chronic medical conditions. She did have a deep venous thrombosis in the year 2001.
• FAMILY HISTORY: Father with colonic cancer; a paternal grandmother with gastric cancer, a
sister with breast cancer; a great aunt with stomach/gastric cancer, a great-cousin with brain
tumor.

4. Deviation
• Left buttocks electron field was treated with the
wrong electron block
• Planned block dimensions: 8.5 cm wide x 7 cm
long
• Treated with a block of dimensions: 8.5 cm wide
x 9 cm long, a breast patients block

8. Explanation
• The electron block was left in the cone from the
previous patients treatment
• The block was not checked before treatment
• The machine may have been behind and in a
hurry when clearing the table of the set up
before this patient, leaving the block in the cone,
then in a hurry when setting up for this patient
and did not stop to check to make sure it was the
correct block

9. Discovery of deviation
• The deviation was discovered after the patient
was treated and the therapist was taking the
block out of the electron cone

10. Dose deviation at c/a
• According to the dosimetrist there is no
compensation
• Because the treatment is with electrons and the
blocks were so close in size
• Electrons are treated to a depth, so even with the
wrong block the patient still got there prescribed
dose, but received extra dose to the surrounding
skin in the 2 cm
• If a small block was used instead of a big block,
scatter would affect the dose received

11. Consequences to patient
• Since the deviation was something that will most
likely not happen again to the same patient,
there are no consequences
• If it did some how continue, the area that the
doctor wanted treated could be missed or cut off
by the block, the patient would not get the same
results, or possibly no results to the area

12. Current practices
• Currently the practice of making sure the correct
block is in for the correct patient is to check and
double check which block is in the electron cone

13. Documentation
• MEDTEC Note: Field 1A treated with cast block
measuring 8.5 cm x 9 cm in dimension. Dr.
Chen notified, no change to treatment plan
needed. DRK
• A brief note should be put in about what
happened, then a deviation report should be
filled out with all of the details

14. Recommendations
• Always remove blocks from electron cone
immediately after treatment
• Do not keep multiple blocks out at the same time
• Check the name on block when setting up the table,
again when setting up the patient and again before
leaving the room
• If someone else setup for the patient check the block
for yourself
• Bring up the image of the electron block for each
setup, to double check your position and make sure
it is the correct shape and block

15. Future advances
• A barcode system could help with treating with
the wrong block
• Each electron block could have a barcode which
is scanned before placing it inside the cone, you
would not be able to treat if the block is not
scanned or it is not the correct block

16. Policy
• When setting up the room get the cone ready and plane
the patient’s block next to it, not inside the cone
• After leveling the patient attach the cone then check the
name on the block and place it in the cone
• Have each therapist that is setting up check the name on
the electron block
• Bring up the image of the block on the computer screen
to verify the shape and position of the block, this could
get rid of uses of the wrong block by noticing it does not
look like the picture
• Before leaving the room after setup is complete recheck
the block