RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience.

PURPOSE: Incident learning is a critical tool to improve patient safety. The Patient Safety and Quality Improvement Act of 2005 established essential legal protections to allow for the collection and analysis of medical incidents nationwide. METHODS AND MATERIALS: Working with a federally listed patient safety organization (PSO), the American Society for Radiation Oncology and the American Association of Physicists in Medicine established RO-ILS: Radiation Oncology Incident Learning System (RO-ILS). This paper provides an overview of the RO-ILS background, development, structure, and workflow, as well as examples of preliminary data and lessons learned. RO-ILS is actively collecting, analyzing, and reporting patient safety events. RESULTS: As of February 24, 2015, 46 institutions have signed contracts with Clarity PSO, with 33 contracts pending. Of these, 27 sites have entered 739 patient safety events into local database space, with 358 events (48%) pushed to the national database. CONCLUSIONS: To establish an optimal safety culture, radiation oncology departments should establish formal systems for incident learning that include participation in a nationwide incident learning program such as RO-ILS.

Facilitation of radiotherapeutic error by computerized record and verify systems.

PURPOSE: To examine the impact of computerized record and verify (R&V) systems on types of radiotherapeutic error. MATERIALS AND METHODS: Radiation therapy treatment errors reported by therapists at the University of Utah between July 1, 1999 and June 30, 2000 were retrospectively reviewed. RESULTS: During a 1-year period in which 22,542 external beam radiation therapy treatments were administered, 38 treatment errors (representing 0.17% of external beam treatments administered during this period) were identified and reviewed. Nine cases (0.04% of treatments) representing four types of record and verify (R&V)-related errors were identified, in which the department's R&V system played a contributory role in the treatment error. CONCLUSIONS: The common denominator among these R&V-related errors was excessive reliance upon the computer system by therapists. R&V systems eliminate some, but not all, pathways of radiotherapeutic error. Although R&V systems have assumed a crucial role in the precise and reproducible delivery of increasingly complex radiation therapy treatments, their inability to eradicate all radiotherapeutic errors coupled with their parallel ability to facilitate certain mistakes mandates vigilance on the part of the radiation therapy team. Radiation therapy treatment procedures must preserve careful oversight of R&V functions to minimize prospects for treatment error.