Quality and Safety

RO-ILS: Radiation Oncology Incident Learning System

RO-ILS: Radiation Oncology Incident Learning System® is a free program that allows practices across the country to contribute patient safety data to a national database via an online portal. The program is tied to a patient safety organization which provides accompanying confidentiality and privilege protections outlined in the federal Patient Safety Act. The mission of RO-ILS is to facilitate safer and higher quality care in radiation oncology by providing a mechanism for shared learning in a secure and non-punitive environment. There is no cost to enroll or participate in RO-ILS thanks to the generous financial contributions of sponsors ASTRO and AAPM and supporters including AAMD. 

Safety experts mine the national database and develop education for the radiation oncology community. RO-ILS education includes safety notices, case studies, themed reports, and aggregate data reports.

Recent RO-ILS education of particular interest to dosimetrists includes:

• New RO-ILS Case Study 19 on wrong vertebral body alignment using auto-registration for SBRT.

• New RO-ILS Releases New Themed Report on Rushing: The new RO-ILS Themed Report contains aggregate analysis comparing rushing and non-rushing cohorts in the database, four case examples, and mitigation strategies. The findings related to problem type, treatment techniques, contributing factors, and more can inform areas requiring additional focus and improvement activities so don’t miss reading this report!

• RO-ILS Case Study 18 discusses the contributing factors that resulted in a discrepancy between patient set up during simulation and treatment.  

• RO-ILS Case Study 16 on prescription transition error and incorrect MUs

• RO-ILS Case Study 15 describes brachytherapy applicator digitalization.

• RO-ILS Case Study 14 describes the limitations of a plan sum and offers 8 mitigation strategies. 

• RO-ILS Celebrates the Great Catches Made by Dosimetrists

• RO-ILS Errors: What Dosimetrists Can Learn From The National Database:  Handouts from the AAMD 2021 Annual Meeting presentation.

• Peer Review Themed Report: A dosimetrist-to-dosimetrist peer review helped identify an incompletely contoured target (Case 5).
• Case Study 7: Multiple staff members missed a patient’s prior spinal radiation and therefore it was not taken into consideration for composite planning.
• Case Study 8: While attempting to treat the first fraction of a high-dose-rate (HDR) brachytherapy case, a staff member could not upload the treatment file to the treatment delivery computer.
• Safety Notice: A systematic error related to SRS heterogeneity corrections affected multiple patients and was difficult to detect.

Safety is No Accident

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Safety is No Accident

Safety is No Accident is a comprehensive reference guide describing the radiation oncology process of care,
the clinical team, safety initiatives and tools and quality management. The document was updated in 2019 and is endorsed by AAMD.  

Consensus Publications

AAMD endorsed or reviewed the following safety-focused documents:

• Editorial: Looking Backward and Forward: Learning From and Updating the ASTRO Safety White Papers 10 Years Later – 2023 Update (ASTRO)
• IMRT – 2023 Update (ASTRO)
• IGRT – 2022 Update (ASTRO)
• SRS/SBRT – 2022 Update (ASTRO)
• Standardizing Nomenclatures TG 283 – 2018 (AAPM)
• Standardizing Dose Prescriptions – 2016 (ASTRO)
• HDR Brachytherapy – 2014 (ASTRO)
• Peer Review – 2013 (ASTRO)

Resource Database

For AAMD documents and presentations, select the “Safety” topic in the Resource Database.