Ro-Ils Paper

Brianna Niemuth
DOS 518 Professional Issues in Medical Dosimetry

October 8, 2020
Mistakes happen, that’s a fact. In Radiation Oncology, as in any medical field, a mistake
could have grave consequences. When a mistake occurs in the medical field best practice is to
investigate the cause, not place blame. Identifying a cause or trend in errors allows for leaders to
implement policies to reduce the chance of the same error occurring again and again. It has also
become best practice to implement policies and educate employees on how to identify and stop
and error before it occurs.
Radiation Oncology is a specialty where any small error can have a large impact on
patients. In January of 2010 the New York times released an article that detailed a case where a
missed computer error lead to an agonizing death for one patient. It also detailed a hospital in
Pennsylvania where many errors were kept quiet for some time.1 This article caught the attention
of many, especially those involved in creating safety measures within Radiation Oncology. In
2011, the American Society for Radiation Oncology (ASTRO), Board of Directors approved a
proposal to establish a national radiation oncology-specific incident learning system.2 This was a
joint effort between ASTRO and the American Association of Physicists in Medicine (AAPM) to
create the Radiation Oncology Incident learning System (RO-LIS). On June 19, 2014 RO-LIS
was officially launched. The goal of creating RO-LIS was to create shared learning across
Radiation Oncology nationwide, allowing institutions and individuals to learn from mistakes that
had been previously made by others; with the hopes that this would in turn reduce the amount
and severity of mistakes made within Radiation Oncology.
Safety events, miss treats or near misses, are recorded are compiled into reports on a
quarterly basis. These events are then analyzed and broken down into several categories as to
what lead up to the event and to look for any trends. My current clinical facility reviews these
reports annually, as we believe it is important to recognize that can and do happen within
Radiation Oncology We look to see if we think this is something that could have happened at
our facility and if we could change anything preemptively to reduce the chances of a similar
event occurring at our site.
Today in Radiation Therapy many patients are imaged daily, to ensure proper alignment.
This can give staff members a false sense of security as they feel they are taking x-rays daily so
the patient must be aligned properly. One event that highlights this involves a patient that was
treated to the wrong vertebral body. The patient was aligned using a 3-point set up and daily
Brianna Niemuth
October 8, 2020
shifts were made. The stereotactic system then requested a 2.5cm shift in the superior/inferior
direction based off CBCT images. The shift was made, and patient was treated. When a
physician was reviewing the films post treatment, they noted that the patient was aligned to the
wrong vertebral body. If we break this event down into categories, we can see a few different
times when this should have been caught prior to the patient being treated.
From a technical standpoint, it should be noted that on this treatment day the vacloc was
not indexed, due to therapist concerns of a collision. By indexing the vacloc therapists would
have noted that the table parameters where were outside of table tolerances. Indexing a vacloc is
a simple way to ensure your table parameters are within tolerance on a daily basis. With an
indexed vacloc therapist can quickly glance at the table parameters prior to leaving the room and
be confident that the patient is in the correct position and any in room shifts were made properly.
The exception to this is on first day, as you do not have table parameters to compare to, however
a physician must review isocenter prior to first day treatment. In this particular center shifts off
of tattoos were unusual, and in this case were forgotten, again the table parameters were not
noted as the vacloc was not indexed. Due to the shifts not being done prior to leaving the room
the sterotacitic localization system requested a 2.5cm shift, which was matching to the incorrect
vertebral body. A shift near the 2 to 2.5cm mark when aligning to a spine should throw a red
flag in any treating therapist mind. The vertebral body itself is about 2-2.5cm when measured
superior to inferior, which means you have shifted about the length of an entire vertebral body
and may very well be aligning to the wrong vertebra.
Looking at how human behavior and leadership affected this situation we can see a new
issue. On the day this error occurred, one of the treating therapists had not yet been trained on the
sterotactic equipment. Without the proper training the second therapist could not serve as a
proper second check and did not feel confident enough to speak up against someone who had
already been trained. In this situation leadership failed to ensure all therapist were properly
trained prior to rotating onto the stereotactic equipment. By ensuring all staff members receive
thorough training prior to using any equipment or technology we can help ensure that staff
members feel confident in their ability to notice and prevent errors, such as the one described in
this story.
Brianna Niemuth
October 8, 2020
It was also noted that this facility also has a policy that any shift over 2.0cm requires that
a resident be paged to the treatment unit to verify isocenter prior to treatment. In this case, the
therapist did not page a resident as “large shifts are common” on this localization system. The
therapist suffered from “alarm fatigue”, which occurs when a person is exposed to frequent
alarms, and as such becomes desensitized to them. The “common large shifts” is something that
should have alerted therapists that something may have been off, however because this happens
so frequently the therapist were comfortable with simply signing off and moving forward.
Although it is impossible to prevent all mistakes, it is essential that institutions strive to
continually minimize the amount and severity of errors occurring within Radiation Oncology.
RO-ILS allows facilities to learn from mistakes that have not yet happened at their facility. By
encouraging facilities to report their errors and allowing everyone to learn from the mistakes, we
can ensure that safety is a top priority within Radiation Oncology.
Brianna Niemuth
October 8, 2020
1. Radiation Offers New Cures, and Ways to do Harm. New York Times Website
https://www.nytimes.com/2010/01/24/health/24radiation.html. Accessed October 6, 2020
2. Radiation oncology incident learning system (RO-LIS). ASTRO website.
https://www.astro.org/ Patient-Care-and-Research/Patient-Safety/RO-ILS. Accessed
October 6, 2020

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Brianna Niemuth

DOS 518 Professional Issues in Medical Dosimetry

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