1

RO-ILS

Martina Stewart

University of Wisconsin-La Crosse

Dos 518-Professional Issues

October 13, 2023

 2

In the field of Radiation Oncology, technology is evolving at a rapid rate to ensure the

delivery of precise and accurate treatment. The emerging technology not only ensures the

advancement of treatment, but also produces unexpected challenges to quality and safety. 1 In

2011, the American Society of Radiation Oncology (ASTRO) board of directors approved a

proposal for a national radiation oncology-specific incident learning system. This standardized

learning system provides an opportunity for all radiation oncology facilities to gain knowledge

from one another regarding incidents that have occurred. ASTRO had partnered with the

American Association of Physicists in Medicine (AAPM) to develop the Radiation Oncology

Incident Learning System (RO-ILS). In radiation oncology, RO-ILS is to date the only medical

specialty society-sponsored learning system.2 The goal of RO-ILS is to provide a safe

environment for clinics to report incidents that occur within their facility to provide education to

others leading to the advancement of safer quality of care.3

A case that was submitted into the RO-ILS system involved a patient that was overtreated

due to a treatment field that was delivered twice in one fraction. After the completion of

treatment, the therapists received a message on the console that stated, “Session Complete” and

they selected “Yes”. After selecting that response, a message appeared stating that the patient

received an ‘underdose’ for the day. The therapists then proceeded to contact the dosimetrist and

between both of them, they could not find any indication that the field had been treated. The only

indication that showed the field being treated was the total dose delivered for that fraction. The

displayed delivered dose was accurate to what it would have been if all the fields were treated. If

it was inaccurate compared to the prescription, then it would be in a red color and in this case it

was not. The dosimetrist proceeded to add another field into the plan for the therapist to treat.

The patient was asked to come back into the treatment room and the therapists treated the patient
 3

with the field that was added. Once the field was delivered, the therapists contacted the physicist

to inform them of the situation that had occurred. The physicist contacted the vendor of the

record and verify system to request the log files for this treatment. log files for the linac and the

record and verify system both confirmed that the field had been treated twice and that the patient

ended up receiving more radiation dose than what was prescribed.

One contributing factor of this incident is the overall lack of communication between all

of the members involved. The therapist initially took the correct step of contacting the

dosimetrist and made sure that the patient stayed and did not leave. The therapist should have

also contacted the physicist in order for there to be more parties involved in the case. Since the

therapist did not contact the physicist, the dosimetrist should have contacted the physicist to

determine what the next plan of action would be. A huddle should have been performed

involving all groups to determine the actual error that occurred between the record and verify

system instead of just assuming that the message of the patient being underdosed was correct. A

huddle between the necessary members would have allowed the opportunity for the error to be

discussed among all members to properly establish a plan of action.1

Another contributing factor to this event was the dosimetrist performing an unauthorized

act outside of their job description. Once the dosimetrist noticed that the record and verify

system was displaying that the dose delivered for that fraction matched the prescription but that

it went against the message of there being an underdosing, that should have been a red flag that

there is some sort of miscommunication occurring. The physicist’s traditional role is to assure

the safe and effective delivery of radiation as it is prescribed.1 Typically, machine

troubleshooting issues are handled by the physicist and not the dosimetrist or they are at least

troubleshooted together. The dosimetrist stepped above their role and performed an act that
 4

should have been decided by or alongside the physicist. Facilities should have a plan of action

and training conducted on who to contact for situations such as this to ensure that the proper staff

is notified and involved.

Many steps could have been taken in this case that would have prevented the unnecessary

overdose of radiation to the patient. Every facility should have a plan of action that is

implemented that involves policies and procedures constructed around a standard of care. All

members that are involved in patient care should be knowledgeable in the roles and

responsibilities of each team member, the treatment planning and delivery process, and steps

taken to ensure continuous quality improvement and safety.1 The RO-ILS learning system will

help to educate other facilities regarding this case in hopes to eliminate the chance of this

medical mistake happening to another patient.

 5

References

1. Safety is No Accident: A Framework for Quality Radiation Oncology Care. ASTRO

Website. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Safety-is-no-

Accident. March 2019. Accessed October 13, 2023.

2. RO_ILS Background. ASTRO Web site. https://www.astro.org/Patient-Care-and-

Research/Patient-Safety/RO-ILS/RO-ILS-Background. 2021. Accessed October 13,

2023.

3. RO-ILS. ASTRO Web Site. https://www.astro.org/Patient-Care-and-Research/Patient-

Safety/RO-ILS. 2021. Accessed October 13, 2023.