1

Brittni McKane

October 30, 2022

Professional Issues

RO-ILS Case Study

Safety is a critical component to healthcare. In radiation oncology, treatment is constantly

changing as technology advances providing opportunities for improvement. At the same time,

this creates a need for a rigorous program of quality assurance, staff education, and

documentation to keep up with the changing technology, equipment, and processes. These

components make up a culture of safety, which is critical to minimize risk to the patient while

maintaining the highest level of care. The American Society for Radiation Oncology (ASTRO)

and the American Association of Physicists in Medicine (AAPM) initiated a Target Safely

program in response to several 2010 radiation error incidents to improve quality and safety of

care in radiation oncology.1 This campaign eventually lead to the debut of the Radiation

Oncology Incident Learning System (RO-ILS), a national error reporting system and safety

database.1 A key component to a patient incident reporting system though is that culture of safety

whereby reporting of incidents is encouraged, just, and treated as an opportunity to learn.2

Background

One case reported to RO-ILS was an instance where the patient was aligned using tattoos

with the radiation therapists then making a daily shift to isocenter. The patient was aligned and

the stereotactic system requested a 2.5 cm shift in the superior/inferior direction. A CBCT was

then completed and made an additional -0.4 cm correction in the superior/inferior direction. An

offline physician reviewing images discovered the isocenter was 2.1 cm off, resulting in

treatment to the wrong vertebral body. This occurred for 1 fraction out of a planned 45 fractions.
 2

Discussion

Patient setup errors are one of the most understandable errors to occur, as there is always

some opportunity for human error. Errors can happen to anyone at any time. Modern simulation

and treatment planning techniques have evolved so that setup tattoos are placed in the general

area of treatment with dosimetry then providing shifts to isocenter for daily treatment. Even with

daily imaging, errors can occur. In a busy clinic, radiation therapists can see 30 or more patients

in a day with each providing an opportunity for an error in shifting to isocenter. These required

shifts are one of the contributing factors to this error. Many clinics require the therapists to apply

the isocenter shifts manually, which could unintentionally result in a shift in the wrong direction.

The second contributing factor to this error was in the daily imaging. Imaging can be a useful

tool but again in a busy clinic with a full schedule it can be easy to overlook minor details.

Especially in the thoracic spine where the vertebral bodies and ribs on a digitally reconstructed

radiograph (DRR) can look very similar when viewing a coned down image.

There are several recommendations that may prevent this error from reaching another

patient. First in regards to the shifting to patient isocenter. Newer technologies allow for

automatic shifting of the couch, thereby eliminating the human error of a therapist manually

shifting the patient in the wrong direction. This option does not address the issue though if the

therapists were to shift in the wrong direction after imaging. A recommendation for that could be

in setting parameters on the treatment machine restricting treatment or requiring additional sign

offs and imaging if shifts are beyond or outside of set tolerances. This could also work in the

same fashion for clinics that are unable to upgrade equipment to utilize automatic couch

movements. The predetermined tolerances could flag the radiation therapists setting up the

patient if a required shift resulted in the table position moving beyond the acceptable tolerance.
 3

Another action would be to require a larger field of view or additional images when treating the

thoracic spine. At my clinical site, it is standard of practice to include within the image a

vertebral body above or below the first or last rib, in order to count the vertebral bodies daily.

This prevents therapists from getting tunnel vision with a coned down image that could easily

confuse vertebral bodies.

As a medical dosimetrist, there are additional ways that we can incorporate safety into

our daily practice. When looking at this specific incident, medical dosimetry can make the

required isocenter shift easier by using whole numbers and only shifting when absolutely

necessary. Additional setup notes with the required shifts and the appropriate direction are also a

simple way to increase safety. Another way that medical dosimetrists can integrate safety is in

the contours that they complete. Some contours could be added to aid in daily imaging. For

example, a vertebral body and rib or other stand out structure can help make localization easier.

These structures could not only aid in matching but also cue the therapists to take a closer look

during daily imaging. Both of these are simple steps that could be added during our normal

routine that could have a profound impact on patient safety.

Conclusion

In the end, incident-learning systems like RO-ILS are a necessary component for

radiation oncology departments to participate. A national reporting system provides multiple

centers the opportunity to learn from each other and enact policies to increase patient safety. The

incident learning system alone is not enough to increase patient safety; it is the culture of safety

and working together with the reporting system to create lasting and effective change.
 4

Reference List

1. Evans SB, Ford EC. Radiation Oncology Incident Learning System: a  call

to participation.  Int J Radiat Oncol Biol Phys. 2014;90(2):249-50.

http://doi.org.10.1016/j.ijrobp.2014.05.2671

2. Arnold A, Ward I, Gandhidasan S. Incident review in radiation oncology. J Med Imaging

Radiat Oncol. 2022;66(2):291-298. http://doi.org/10.1111/1754-9485.13358