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Keith Larsen
DOS 518 Professional Issues
October 3, 2021
Radiation Oncology Incident Learning System Case Study
Radiation oncology is a constantly evolving field, continuously introducing new
technologies that need quality assurance on equipment and staff training to ensure safe use on
patients. Due to the nature of the field where potentially lethal doses of radiation are used, any
minor human error has the potential to lead to dramatic results. As such, it is vitally important to
create cultures of safety that minimize risk to patients as well as putting staff in a position to
succeed. In response to several high profile stories in the news around 2010 calling into question
the general safety of radiation oncology, the American Society for Radiation Oncology
(ASTRO) and the American Association of Physicists in Medicine (AAPM) created a Target
Safely program aimed at increasing safety in radiation oncology as well as improving trust in the
field from the general public.1 In 2014, the Target Safely initiative introduced the Radiation
Oncology Incident Learning System (ROILS) program which created a public database of
incidents within the field to allow for examination of failures in process and how to best prevent
them from happening in the future.
One case reported to ROILS was an instance where a patient was lined up for treatment
using their tattoos. Shifts were made off of the patient’s tattoos in the superior to inferior
direction. A cone beam CT scan (CBCT) was performed, and fine tuning adjusts were made off
of the imaging. Upon review of the imaging following the treatment, the physician found that the
therapists had mistakenly aligned to the wrong vertebral body resulting in a treatment delivered
that was off of isocenter by 2.1 cm. This occurred for 1 fraction out of a total of 45.
The pathway that led to the error is unfortunately very understandable, and a good
example of why programs such as ROILS are such a valuable addition to the field. With modern
treatment planning, it is very common to place arbitrary setup tattoos at simulation and have
dosimetry give shifts to get to isocenter for daily treatment. In clinics where there are upward of
30 patients being treated in a day, the therapists can have a lot of mental math in calculating
these shifts and opportunities for error. Daily imaging has become standard within the field, but
it can be easy to have tunnel vision when image matching and align to a wrong structure. This is
particularly true in the region of the chest, where the thoracic spine structures look extremely
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similar from one body to the next. The therapists could very well follow policy correctly, but
human error can occur, and mistakes will happen.
One contributing factor to errors such as this are the necessity of shifts. Most centers
require the therapists to manually calculate the shifts and apply them. Shifts can be made
incorrectly; it is common to move the opposite direction than what is intended, or simply
calculate the math incorrectly. A second contributing factor was the imaging. Though daily
imaging is one of the best and safest ways to ensure correct treatment position, care must be
taken to ensure it is done correctly. Distractions can happen, or error could occur by not being
careful and taking an extra moment to verify by other surrounding structures that the image
match is indeed correct.
There are several actions that could be taken to address both of these issues. In regard to
patient shifts, a great and accessible option for all centers is to make indexing patient setups
mandatory. By locking immobilization devices into set positions on the treatment couch and
setting parameters on the treatment machine to not allow treatments outside of tightly acquired
windows (tolerance tables), the chance of shifting the wrong direction or incorrectly has a much
greater chance of getting caught as the machine would alert you to being outside of expected
position. Newer technologies allow for automatic couch movements that do any pre-image daily
shifts automatically, so the therapist does not have to mentally calculate shifts and risk getting
them wrong.
As for not catching the error on imaging, one simple solution is for dosimetry to contour
additional structures. Though CBCT and kilovoltage (KV) imaging have greatly improved
quality than imaging used in years past, contrast can still be low and differentiating vertebral
bodies can be difficult. Contouring structures such as the carina can greatly aid in correct
positioning as it is a separate structure that shows up clearly to verify positioning. Furthermore,
ensuring that a second therapist is confirming the image match is part of the time out procedure
is an additional line of safety. Multiple studies including one by Kalapurakal et al2 have
confirmed that including checklists and safety timeouts prior to delivery treatment is a very
effective method in decreasing treatment errors. Taking the moment in the timeout to verify
correct positioning can be the one extra check needed to catch the error before treatment is
delivered incorrectly.
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This scenario is a great example of why programs like ROILS are necessary for radiation
oncology departments to participate in. This patient was fortunate in this being a 2cm positioning
error only once out of 45 treatments. But by submitting this error to ROILS, other centers may
have the opportunity to see what happened and implement policies to prevent this, or a more
severe version, from happening. Further, by submitting errors to a large database, more common
mistake patterns may be noticed and allow for vendors to add in extra safety mechanisms, such
as the automatic couch shift movements discussed previously, or for departments to adjust policy
accordingly.
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References
1. Evans SB, Ford EC. Radiation Oncology Incident Learning System: a call to
participation. Int J Radiat Oncol Biol Phys. 2014;90(2):249-250.
doi:10.1016/j.ijrobp.2014.05.2671
2. Kalapurakal JA, Zafirovski A, Smith J, et al. A comprehensive quality assurance program
for personnel and procedures in radiation oncology: value of voluntary error reporting
and checklists. Int J Radiat Oncol Biol Phys. 2013;86(2):241-248.
doi:10.1016/j.ijrobp.2013.02.003