The radiation oncology incident learning system (RO-ILS) has been active in the USA for almost a decade. Overseers regularly publish safety education and incident-related information. The system is embedded in a patient safety organisation, which ensures confidentiality and protection of the data. The programme is sponsored by the American Society for Radiation Oncology (ASTRO) and the American Association of Physicists in Medicine, and it is supported by other societies and vendors such as Varian and Sun Nuclear Corporation.

A themed report entitled ‘Dosimetrically Impactful Events’ was recently published. The report gives a short introduction and overview of the purpose of the system and the incidents reported. It then details five reported cases, three of which were identified as of the highest severity level and two as 3D events. The section on highest severity events gives a short synopsis of the three incidents: stereotactic treatment of incorrectly contoured brain tissue, wrong lesion retreated, and the wrong anatomical site treated with brachytherapy. It continues with explanations of topics of concern, using multiple data points to describe what types of errors were reported in these dosimetrically impactful events. These are then reviewed and analysed in terms of the dosimetric impact and important factors to consider in understanding the errors. There is a section on error discovery in terms of who identified the event; this is consistent with previous publications, and the data show that radiation therapists were the lead identifiers, followed closely by medical physicists. The report also considers steps during workflow that are error-prone. Treatment delivery scores highest in numbers of errors in both occurrence and discovery.

Two cases are cited in the 3D events: patient not returned to treatment position after being moved for reference point mark-up; and patient aligned to incorrect anatomical landmarks.

The RO-ILS management has been very positive in sharing its findings and analysis, and the attached report is an example of the details to be found on the ASTRO website. The radiation oncology safety and quality committee, through the radiation oncology safety and education information system, aims ultimately to share information with the RO-ILS programme to enable analysis of a wider dataset and to consider whether the same incidents and influencing factors are consistent globally or whether there are variations that we can learn from.

https://www.astro.org/ASTRO/media/ASTRO/Patient%20Care%20and%20Research/PDFs/ROILS_TR_Dosi.pdf

Mary Coffey

Adjunct associate professor in radiation therapy
Department of Medicine
Trinity College Dublin
Dublin, Ireland