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Haley Kroeplin
DOS 518 Professional Issues
September 26, 2020
Radiation Oncology Incident Learning System (RO-ILS) Case Study

Radiation therapy is a therapeutic treatment modality used to treat a wide variety of

cancer patients with curative or palliative intent. Although most treatments are delivered safely
and effectively, there have been a few incidents that have received national attention in the past
due to catastrophic treatment errors.1 In light of these unfortunate events, the American Society
for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine (AAPM)
developed the Radiation Oncology Incident Learning System (RO-ILS) in June 2014, through
ASTRO’s Target Safely program.2 The mission of this national error reporting system is to
promote safe and superior quality of care in radiation oncology by implementing a database for
institutions to learn from each other in a secure and non-disciplinary setting in order to prevent
similar mistakes occurring in their departments in the future.3 Since its introduction in 2014,
more than 550 United States healthcare organizations have joined RO-ILS to provide patient
safety information to the database.2 The following case was logged into the RO-ILS and will be
evaluated with a focus of identifying what went wrong in the process and providing
recommendations that may prevent the mistake from occurring again.
The specifics of this case are as follows: for one fraction out of course of 45 fractions, a
patient’s radiation therapy treatment was delivered to the wrong vertebral body. The patient was
positioned in a stereotactic body fix system and aligned to their three-point tattoos. Once the
patient’s tattoos were aligned with the lasers in the room, the therapists stepped out of the room
to perform daily shifts from the tattoos to the isocenter. On the day that the error was made, the
stereotactic system requested a shift of 2.5 cm in the sup/inf direction which was applied by the
therapists. A conebeam computed tomography (CBCT) was performed thereafter and a -0.4 cm
correction was made in the sup/inf direction. This resulted in a total offset from the correct
isocenter to be 2.1 cm. It wasn’t until after the treatment, that a physician who was reviewing the
CBCT images noticed that the radiation therapy treatment was delivered to the wrong vertebral
body.
Upon evaluation of this incident submitted to the RO-ILS, there are a couple contributing
factors that led to this adverse event in which the radiation therapists administered a patient’s
radiation therapy treatment to the incorrect vertebral body. If this error occurred during the first
treatment, one of the contributing components would have been the lack of members of the
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Haley Kroeplin
DOS 518 Professional Issues
September 26, 2020
radiation oncology team, such as the radiation oncologist and radiation therapists, present during
the time out or procedural pause prior to treatment. Having various radiation oncology team
members present to verify and agree that the correct vertebral body was localized prior to
treatment delivery would have prevented this error. In addition, this would have eliminated the
error being caught post treatment when a physician was reviewing the patient’s offline CBCT
images. If this error occurred during a subsequent treatment, the therapists could have called a
time-out to double check that the patient was setup correctly and that the correct patient chart
was pulled up. If everything was correct, they should have called a physician to review images if
they were questioning why the stereotactic system calculated a larger than normal shift for this
patient. By taking the time to verify alignment or question unusual shifts, would have hopefully
resulted in a ‘good catch’ and ‘near miss’ rather than a treatment error.
The second contributing factor that led to this error is not verifying the vertebral level
with onboard imaging (OBI). It is well known that without including bony landmark anatomy,
such as the base of skull, first or twelfth thoracic vertebra, or the fifth lumbar spine, localization
of the correct vertebral level can be difficult. During this incident, the radiation therapists could
have shifted the OBI imager to include one of these landmarks in order to count the vertebral
bodies and identify the correct level for treatment prior to utilizing the stereotactic system or
CBCT. Furthermore, they could have also verified the vertebral level after they noticed that a
greater than 2 cm shift was noted with initial imaging. Establishing institutional imaging
guidelines about verifying vertebral level with OBI prior to additional imaging or requiring
verification of vertebral level with OBI if shifts are greater than 2 cm in any direction would
ensure that another radiation therapy treatment delivered to the wrong vertebral body would not
occur.
Although mistakes can happen, it is imperative that institutions learn from the errors
reported in the RO-ILS and develop protocols that would prevent a similar error from occurring
within their departments. As noted by Hendee et al4 empowering team members to declare a time
out if they have any questions or concerns about a patient’s treatment and establishing standard
operating procedures can diminish errors in radiation oncology. By incorporating these
recommendations within a radiation oncology department, ensures that patient safety is the
primary focus and responsibility of all team members.
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Haley Kroeplin
DOS 518 Professional Issues
September 26, 2020
References

1. Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Safety strategies in an academic

radiation oncology department and recommendations for action. Jt Comm J Qual Patient Saf.
2011;37(7):291-299. https://doi.org/10.1016/s1553-7250(11)37037-7
2. Evans SB, Ford EC. Radiation oncology incident learning system: A call to participation.
International Journal of Radiation Oncology Biology Physics. 2014;90(2):249-250.
https://doi.org/10.1016/j.ijrobp.2014.05.2671
3. Radiation Oncology Incident Learning System. American Society for Radiation Oncology
website. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS. Accessed
October 1, 2020.
4. Hendee WR, Herman MG. Improving patient safety in radiation oncology. International
Journal of Radiation Oncology Biology Physics. 2010;38(1):78-82.
https://doi.org/10.1118/1.3522875