ROILS – Professional Issues

Amanda Tabar

In this particular case, a patient in need of whole brain radiation therapy was being

prepared for treatment. The setup process involved the presence of two therapists and a

physician; however, a significant error occurred when one of the therapists erroneously measured

the patient's head using the incorrect scale side on the calipers. This erroneous measurement

resulted in a significant 28% overdose in radiation dose during treatments. The error went

unnoticed until Monday, when the Dosimetrist identified the error while reviewing the treatment

plan. Unfortunately for this patient, this series of events was not noticed until after it was too

late, as treatment had already begun.

Retrospectively, this case can serve as an example of the errors that occurred and provide

valuable insights into how we can learn lessons from it for future improvements. The therapist

responsible for taking the patient's head measurement made a critical measurement error by

selecting the wrong side of the calipers. This error, which led to an inaccurate measurement of 30

cm, subsequently resulted in the treatment unit being set up based on the incorrect measurement;

and consequently, resulted in the patient received a 28% overdose of radiation during treatments.

Two significant contributing factors played a role in this incident. The primary factor was human

error, as the therapist incorrectly used the calipers, causing a critical measurement mistake. The

second factor was the absence of verification, or double-checking of measurements at various

stages of the process, which allowed the error to persist and affect the patient's treatment.

To prevent similar errors in the future, it is essential to implement a strict double-

verification process for all critical measurements taken during patient setup. This process should
involve a second therapist independently verifying the initial measurement and cross-checking

the setup parameters to ensure accuracy and consistency. Additionally, regular training and

refresher courses should be provided for therapists and other staff involved in the treatment

process. This training should emphasize the significance of precise measurements, proper

equipment usage, and the necessity of error reporting. Moreover, conducting routine quality

control checks on equipment and processes can help identify and mitigate potential errors

proactively.

The implementation of the Radiation Oncology Incident Learning System (ROILS) holds

significant importance in enhancing patient safety and error prevention within the field of

radiation therapy. ROILS was implemented in June 2014, and is a comprehensive reporting and

learning system designed to collect data on safety events and near-misses in radiation therapy. Its

goal is to ensure safety and quality of care by providing a system that is dedicated to tracking

incidents, near misses and unsafe conditions1. This system facilitates the systematic

documentation of incidents, enabling in-depth analysis and the sharing of lessons learned.

ROILS enables healthcare professionals to report incidents and errors systematically, helping to

identify patterns and root causes of errors; this data can then be used to implement corrective and

preventive actions. ROILS also promotes shared learning by allowing professionals to share

anonymized incident reports; and by doing so, healthcare providers can benefit from the

experiences and insights of others. Finally, ROILS supports continuous improvement by

collecting data that can be used to develop and implement strategies for error prevention and

system enhancement. By continuously monitoring and analyzing incidents, healthcare providers

can proactively address potential risks and enhance patient safety within the field of radiation

therapy.
 In conclusion, this case of a critical error underscores the importance of rigorous quality

control, training, and the implementation of a double-verification process. Human errors in

radiation therapy can have severe consequences, necessitating proactive measures to prevent

future mishaps. Some important steps that can be taken include efforts put forth at the level of

supervision, including access to education, training and a culture of safety being the standard2.

The implementation of the ROILS system in radiation therapy has become key in identifying,

analyzing, and learning from incidents, thereby enhancing patient safety and the overall quality

of care provided in the field.

References:

1 American. RO-ILS- American Society for Radiation Oncology (ASTRO) - American Society

for Radiation Oncology (ASTRO). American Society for Radiation Oncology. Published 2016.

Accessed October 18, 2023.

https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS#:~:text=The

%20mission%20of%20RO%2DILS

2. Weintraub SM, Salter BJ, Chevalier CL, Ransdell S. Human factor associations with safety

events in radiation therapy. Journal of Applied Clinical Medical Physics. 2021;22(10):288-294.

doi:https://doi.org/10.1002/acm2.13420