Carli Doerr

DOS 518- Professional Issues

Radiation Oncology Incident Learning System (ROILS) Case Study

Throughout the late 1990’s and early 2000’s, radiation treatments were becoming more
complex due to technological advances. Intensity Modulated Radiation Therapy (IMRT) became
an option for treatment techniques as well as some other improved developments. These
advances also changed how treatments were tested in quality assurance procedures as well as
how they were approved in the record and verify system. All of the changes made it critical for
radiation staff to monitor and execute the precise and correct treatments. Changes create
opportunities, but they can also create various places for errors to occur. In 2010, the New York
Times featured articles about accidents with radiation therapy treatments that resulted in death.1, 2
The public was becoming more aware of the dangers of radiation. Shortly after this, the
American Association of Physicists (AAPM) and the American Society of Radiation Oncology
(ASTRO) conducted a meeting to develop a system that would reduce errors. This is when the
Radiation Oncology Incident Learning System (ROILS) was developed to improve patient safety
by learning from past errors.3 The mission of the ROILS is to help develop a higher quality of
care in radiation oncology by providing this system where shared experiences and mistakes can
be learned from in a non-disciplinary environment.4

One such situation that was imported into the ROILS revealed an incorrect amount of
dose that was delivered for 2 fractions to a patient receiving treatment to the whole brain. This
patient was treated over the weekend when full staff was not available. Only two therapists and
the physician were present for the patient’s setup. The simulation for the patient was setup
clinically on the treatment machine. One of the therapists measured the patient’s head with
calipers reading a 30 cm lateral separation. The therapist was unaware that the measurement was
attained from the incorrect scale side of the calipers. This resulted in a dose difference of 28%
for the 2 fractions of treatment this patient received over the weekend. On the following
Monday, the dosimetrist caught the error when creating a formal plan for the patient.

Two major factors that contributed to this error include the lack of checking the work of
others as well as insufficient training of the staff. Hendee et al5 explained the importance of
patient safety in radiation oncology and how it can be improved. In a list of hazard mitigation
effectiveness with the article, training and education as well as policies and procedures were
included.5 There was also a table developed by ASTRO in the article that listed a six point action
plan to improve safety of patient undergoing radiation therapy. In the table, they included the
importance of expanding education and training programs to include intensive focus on quality
and safety. They also included advocating for the CARE (Consistency, Accountability,
Responsibility, Excellence in Medical Imaging and Radiation Therapy) act.5 To prevent errors
like this one from occurring, certain steps and plans of action need to be taken.

This situation was introduced into the ROILS so other clinics and departments could
develop ideas on how to prevent mistakes such as these from happening. My clinic is a fine
example of a major institution that treats a wide range of cancers using many different types of
machinery and systems. Because of this wide range of capabilities and multiple linear
accelerators, it requires a large staff to run the place. We treat usually over 100 patients a day.
This calls for the necessity of strict policies and procedures and thorough training of the radiation
staff to make sure they all understand their roles and responsibilities. This helps to keep
everything in order without any potential errors. My clinic has unfortunately had the experiences
where mistakes were made, but they always have called meetings to develop systems on how to
prevent the same mistakes from happening.

One such example of my clinic developing better safety is through the well-developed
training program for the weekend call therapists. These therapists are specifically chosen for
their prestigious work and dependability knowing the types of responsibilities that fall on their
shoulders as weekend call therapists. Before these therapists are allowed to take on that
responsibility completely, they are enrolled in a training program where they learn all the
methods and procedures involved in a weekend simulation and treatment case. Each therapists
has to pass off competencies to show they understand all of the policies and procedures involved
and allowed for weekend treatments. The doctors are also trained to understand that only certain
simple cases can be simulated and treated on the weekend. If the treatment is too complex, then
the doctors are told to wait for the following Monday when a full staff can be present to ensure
safety. Dosimetrists are also involved in this training program to make sure the therapists
understand each and every role they are allowed to perform. It is a very thorough training
program which remains constant and reliable held every Friday morning in the department
rotating between the different therapists. During this training, they are also made sure to
understand that they need to remain vigilant in checking the work of their coworkers.

Working in a team can be very beneficial, but it also becomes crucial to check the work
of your teammates. Therapists should not ever rely on their teammates to be performing the
correct and accurate work that needs to be done. Second checks should always be done to ensure
the safety of everyone involved. This is another important role that my clinic stresses to everyone
involved in the radiation staff. It doesn’t matter if the person’s work that is being checked has
more authority, everyone can make mistakes which is why it is important to double check the
work of others. In this case study that was submitted to ROILS, the therapist’s work should have
been double checked by the other therapist that was working that weekend. Two people should
have read the measurement from the calipers to verify the correct measurement. The mistake
might have been caught and corrected. Because radiation therapy is such a dangerous yet
amazing entity, it deserves the respect from everyone involved in the procedures to ensure safety.
 References

1. Bogdanich W, Rebelo K. A Pinpoint Beam Strays Invisibly, Harming Instead of Healing.

2. Bogdanich W. Radiation offers new cures, and ways to do harm. The New York Times.
https://www.nytimes.com/2010/01/24/health/24radiation.html. Published January 23,
2010. Accessed October 8, 2020.

3. Hoopes DJ, Dicker AP, Eads NL, et al. RO-ILS: Radiation Oncology Incident Learning
System: A report from the first year of experience. Pract Radiat Oncol. 2015;5(5):312-
318.

4. RO-ILS- American society for radiation oncology (ASTRO) - American society for
radiation oncology (ASTRO). Astro.org. https://www.astro.org/Patient-Care-and-
Research/Patient-Safety/RO-ILS. Accessed October 8, 2020.

5. Hendee WR, Herman MG. Improving patient safety in radiation oncology: Improving
patient safety in radiation oncology. Med Phys. 2011;38(1):78-82.
https://doi.org/10.1118/1.3522875