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Jessalyn Mitchem
DOS 518
ROILS Case Study
October 10, 2023
Introduction
The Radiation Oncology Incident Learning System (ROILS) is a system used in the field
of radiation oncology to track and analyze incidents, errors, or near-misses in the treatment of
cancer patients with radiation therapy. ROILS was developed by the American Association of
Physicists in Medicine and the American Society for Radiation Oncology (ASTRO) in order to
develop a standardized system for incident learning.1 ROILS is designed to promote a culture of
safety and continuous improvement by allowing healthcare providers to report and learn from
these incidents, and enhance patient care and safety in the radiation oncology practice. In this
paper, I will discuss a case study that was logged into ROILS.
Case Study
In this case study, a patient required whole brain radiation over the weekend. Two
therapists and the physician were present for the patient's setup. The patient was set up clinically
on the treatment unit. One therapist measured the patient's head with a lateral separation of 30
cm using the incorrect scale side on the calipers. This resulted in a 28% in dose over 2 weekend
treatments. The error was caught on Monday by the Dosimetrist when a formal plan was
completed.
Discussion
While there were several contributing factors that led to the mistreatment of this patient,
one of the primary contributing factors to the case was human error. A therapist measured the
patient’s head with a lateral separation of 30 cm. Unfortunately, this was an incorrect
measurement. Such errors can occur when the therapist may have not been paying attention or
was stressed out due to the emergent patient. The physician was also present for the patient’s set
up in this case, but he/she may not have been paying attention or simply trusted that the
therapists would not mess up. Unfortunately, this was another layer of human error that added to
the situation. Additionally, the incident underscored a lack of a double-check procedure, which
could have prevented the error.
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In healthcare, a double-check procedure is a safety protocol designed to reduce the risk of

errors. It involves two healthcare professionals independently verifying information or actions to
ensure accuracy. Without a standardized protocol for a second therapist to independently verify
measurements or a checklist process, the error went unnoticed until much later in the treatment
process. I have learned from personal experience when treating an emergency patient over the
weekend, that double-check procedures are essential. There are too many opportunities for
human error to occur when trying to take care of a sick patient and calculate their treatment at the
same time. Navigating the machine console in emergency treatment mode can also add a layer of
uncertainty, and so it is vital that the therapists in this case should have checked every step of the
process at least twice before they actually treated the patient.
This case study provides a perfect example of why Continuous Quality Improvement
(CQI) in radiation oncology is important. The presence of a CQI team in radiation oncology can
help provide input on the impact of the error and propose solutions or recommended changes if
they are necessary.2 CQI also encourages a culture of open reporting for any incidents or near
misses so that problems in the radiation therapy process can be addressed.2 A fundamental step
to prevent errors like this from happening is to establish a double-check procedure for critical
measurements in radiation therapy setups. The procedure should involve a second therapist, who
independently verifies all measurements and calculations before any treatment is delivered. This
acts as a safety net, ensuring that any potential discrepancies are caught before they can impact
the patient. Double-check procedures are a fundamental part of patient safety protocols in
healthcare settings.
Continuous training and education are essential components of maintaining patient
safety. Radiation therapy staff should undergo regularly quality assurance training such as
emergency treatment procedures, in order to ensure accuracy, precision, and attention to detail in
every step of patient care. In personal experience treating as a radiation therapist, emergency
treatment procedures made me nervous as they did not happen very often. Because of this,
someone more senior than I came with me several times to check my calculations and ensure
proper treatment of the patient. By standardizing emergency treatment procedures, every
member of staff will have the same knowledge and be well-prepared to handle any situation.
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Conclusion
The primary responsibility of healthcare professionals in radiation therapy is to provide
effective treatment while prioritizing patient safety and minimizing potential risks associated
with radiation exposure. The incident involving the measurement error for this case study serves
as a stark reminder of the importance of proactive safety measures in radiation oncology. By
addressing the contributing factors through the implementation of a double-check procedure and
investing in ongoing quality assurance training, any future incidents can be prevented.
Prevention is key in maintaining the high standard of care to those in need.
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References

1. Ro-ils background - American Society for Radiation Oncology (astro) - american society
for radiation oncology (Astro). American Society for Radiation Oncology. Accessed
October 4, 2023. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-
ILS/RO-ILS-Background.
2. Safety is no accident - American Society for Radiation Oncology. 2019. Accessed
October 6, 2023.
https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/PD
Fs/Safety_is_No_Accident.pdf.