Jenn DeWeese

DOS 518-Professional Issues

October 13th 2023

Radiation Oncology Incident Learning System (RO-ILS) Case Study

In 2011, the American Society of Radiation Oncology (ASTRO) and the American

Association of Physicists in Medine began working on the Radiation Oncology Incident

Learning System (RO-ILS) in collaboration with the Clarity Patient Safety Organization. This

system became available nationwide in June 2014, with 139 practices and 336 facilities

participating by May 2017, and over 3,300 event reports submitted.1 These reports are evaluated

by a group called the Radiation Oncology Healthcare Advisory Council (RO-HAC), consisting

of professionals in the field. The RO-HAC produces quarterly reports with statistics, case

studies, and recommendations for improving practices. This council operates independently

from ASTRO and the American Association of Physicist in Medine (AAPM).2

These reports can offer insight into how errors in radiation oncology treatments occur,

how they are discovered, and how they are resolved. Although the self-reported data have biases

and uncertainties, analyzing a group of the most significant reports can help identify recurring

patterns of errors and their causes. By creating fault trees to diagram these error pathways,

attention can be drawn to these recurring issues and facilitate the development of strategies to

mitigate them.3

One case study presented to the RO-ILS committee was a mistake on a caliper

measurement. A patient needed whole brain radiation therapy over the weekend. Two therapists

and a physician were present for the patient's setup. During the setup process, one therapist
measured the lateral separation of the patient's head as 30 cm but inadvertently used the incorrect

scale side on the calipers. As a result, the lateral separation was inaccurately determined, leading

to a 28% overdose in radiation dose over the course of two weekend treatments. The error was

only detected on Monday when the dosimetrist completed a formal treatment plan.

The error in this case occurred during the patient setup and initial treatment planning

process. The primary contributing factor was a measurement error made by one of the therapists.

The therapist measured the lateral separation of the patient's head using the incorrect scale side

on the calipers, resulting in an inaccurate measurement. This error had a cascading effect, as it

directly changed the calculation of the treatment dose and led to the significant overdose.

There also was a lack of immediate verification following the measurement. In radiation

therapy, it is crucial to have a verification process in place to confirm the accuracy of

measurements and treatment parameters before the actual treatment is administered. In this case,

the error went unnoticed during the weekend treatments, highlighting the importance of double

checks and verifications.

To prevent similar errors from occurring in the future a double-check and verification

protocol should be in place. Before administering the radiation additional people (a physician, a

physicist or another therapist) should independently verify and cross-check measurements to

confirm accuracy. This includes the use of appropriate measurement tools and calibration.

It is also very important to encourage a culture of immediate feedback and reporting of

any discrepancies or uncertainties in the treatment process. Reporting errors provides valuable

data for trend analysis and quality enhancement, fosters trust, and ensure that healthcare

professionals meet legal and ethical obligations.4

References

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

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

Radiation Oncology. Published 2016. Accessed October 13, 2023.

https://www.astro.org/Patient-Care-and- Research/Patient-Safety/RO-ILS/RO-ILS-

Background.

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

Radiation Oncology (ASTRO). ASTRO. Published 2016. Accessed October 13,

2023. http://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS.

3. Ezzell G, Chera B, Dicker A, et al. Common error pathways seen in the RO-ILS data that

demonstrate opportunities for improving treatment safety. Practical Radiation Oncology.

2018;8(2):123-132. doi: https://doi.org/10.1016/j.prro.2017.10.007

4. Smith R. Peer review: a flawed process at the heart of science and journals. Journal of

the Royal Society of Medicine. 2006;99(4):178-182.

doi:https://doi.org/10.1258/jrsm.99.4.178