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ROILS Case Review

Unfortunately, medical errors occur throughout healthcare, and radiation oncology is no

exception. In a technologically advanced field where healthcare professionals are providing high
dose radiation treatment to patients, the possibility exists for both human error and technology
malfunction. Sometimes catastrophic errors can occur as a result when both humans and
computers fail to follow expected procedures. In a field where the potential exists for many
different types of error, it is important to be able to identify broken workflows and flawed
technology in an effort to minimize risk and patient harm. This is called quality improvement.

Quality improvement is a proactive and continuous effort towards improving health care
processes in an effort to reduce medical errors.1 It requires the training of and participation from
all staff and places responsibility for process improvement on every employee. Additionally,
continuous quality improvement relies on data collection for decision-making and process
analysis. One tool developed to improve safety in radiation oncology and sponsored by ASTRO
and AAPM is the Radiation Oncology Incident Learning System, or ROILS.2 ROILS is a
national web-based portal with participation from more than 500 radiation oncology departments
that allows employees to report near-misses, incidents, errors, and unsafe conditions in a non-
punitive manner. ROILS then tracks and reports the incidents allowing participating
departments to learn from one another.

One particular case logged into ROILS caught my attention. In this incident, two
therapists and one radiation oncologist were performing an emergent whole brain treatment over
the weekend using a clinical setup. One radiation therapist measured the lateral separation of the
patient’s head to be 30 cm and this measurement was used in the monitor unit calculations for
two weekend treatments. When a dosimetrist worked on a formal treatment plan on Monday, it
was discovered that the therapist had read the incorrect scale on the calipers when measuring the
patient’s lateral separation, resulting in a 28% discrepancy in delivered dose.

The measurement of 30 cm is an excessive separation for a brain that should have raised
questions at the time of the calculation. Additionally, there were several other factors that
contributed to the error in the dose calculations and mistreatment of the emergent whole brain.
One contributing factor is that not only did the therapists and radiation oncologist not question
the measurement, but nobody verified it with a double check. Because both humans and
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computers can make mistakes, double checking all measurements and parameters should be
standard when performing a monitor unit calculation. In this case, even if the therapists had
bothered to document a TSD reading, they might have noticed that the depths used for their
monitor unit calculations were off in comparison to the TSD reading. Another contributing
factor that led to this error is the inappropriate use of the calipers used to make the measurement.
Either the therapist who made the measurement did not know how to use the calipers or the
scales on the calipers were not clearly marked. Regardless, all of the tools used in radiation
therapy should be in proper condition and used by individuals who know how to utilize and read
them correctly.

Since the goal of quality improvement and the ROILS database is to learn from previous
mistakes, it is important to consider how to prevent the same mistake from happening in the
future. One recommendation to avoid this type of error would be to institute a time-out policy
prior to treating clinical setups. A time-out would require the signatures of two therapists and
would require verifications of all manual measurements and calculations as well as all computer
parameters. Another recommendation to prevent a similar error would be to provide more
training for staff involved in emergent clinical simulations and treatment. Knowledge and
understanding of procedures are critical for the safe treatment of patients, and the stress during
an emergency can put pressure on staff to carry out procedures in which they are not fully
comfortable. In this case, the staff involved did not know how to properly use the calipers
required for the clinical sim measurements and did not have the experience necessary to question
a 30 cm lateral separation for a whole brain. New staff training programs as well as routine
refreshers for experienced staff could help to provide the staff involved in clinical sims more
experience and confidence for when an emergent situation arises. In this ROILS case, perhaps
the clinical sim and treat would have been more successful if the above mentioned verification
checks were in place and the therapists had the proper training to prepare them for an emergent
treatment.

In conclusion, although mistakes in radiation oncology can never be eliminated, it is a

vital responsibility of all professionals to reduce risks as much as possible in an effort to provide
our patients with the safest care. In addition to the continuous review of procedures, workflows,
and departmental errors and near-misses, we must learn from the mistakes of others and be
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willing to make changes. Because of this, quality improvement is most effective when it is
integrated in our daily work.

References

1. Lenards, Nishele. Continuous Quality Improvement. [Soft Chalk.] La Crosse, WI: UW-L
Medical Dosimetry Program, 2019.
2. ASTRO. RO-ILS: Radiation Oncology Incident Learning System.
https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS. 2019. Accessed
September 29, 2019.