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

Hoopes, D.J.; Dicker, Adam P.; Eads, Nadine; Ezzell, Gary A.; Fraass, Benedick A.; Kwiatkowski, T; Lash, Kathy; Patton, Gregory A.; Piotrowski, Tom; Tomlinson, Cindy; Ford, Eric

doi:10.1016/j.prro.2015.06.009

Cited by 73 publications

(54 citation statements)

References 15 publications

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“…For programs which do not have a departmental incident learning system, it may be possible to review case studies from the literature or from RO‐ILS™: Radiation Oncology Incident Learning System25 which are publicly available 26. It can be expected that this will be less of an issue in the future since departmental incident learning systems are specifically called for by ASTRO and other professional societies12 and, in the US at least, will be incentivized by reimbursement models under the new MACRA rules.…”

Section: Discussionmentioning

confidence: 99%

“…The needs of the educational program may provide an additional impetus for engaging in such a program. The tools for incident learning in radiotherapy are now well understood and described in the literature18, 27, 28 and specialty‐specific systems are available, such as the RO‐ILS system25 sponsored by ASTRO and AAPM and the Center for Assessment of Radiological Sciences PSO system (cars‐pso.org). Related to this is the need for a strong culture of safety, which is a driving force for quality care.…”

Section: Discussionmentioning

confidence: 99%

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A patient safety education program in a medical physics residency

Ford

Nyflot

Spraker

et al. 2017

J Applied Clin Med Phys

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Education in patient safety and quality of care is a requirement for radiation oncology residency programs according to accrediting agencies. However, recent surveys indicate that most programs lack a formal program to support this learning. The aim of this report was to address this gap and share experiences with a structured educational program on quality and safety designed specifically for medical physics therapy residencies. Five key topic areas were identified, drawn from published recommendations on safety and quality. A didactic component was developed, which includes an extensive reading list supported by a series of lectures. This was coupled with practice‐based learning which includes one project, for example, failure modes and effect analysis exercise, and also continued participation in the departmental incident learning system including a root‐cause analysis exercise. Performance was evaluated through quizzes, presentations, and reports. Over the period of 2014–2016, five medical physics residents successfully completed the program. Evaluations indicated that the residents had a positive experience. In addition to educating physics residents this program may be adapted for medical physics graduate programs or certificate programs, radiation oncology residencies, or as a self‐directed educational project for practicing physicists. Future directions might include a system that coordinates between medical training centers such as a resident exchange program.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

A patient safety education program in a medical physics residency

Ford

Nyflot

Spraker

et al. 2017

J Applied Clin Med Phys

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“…One such stream of information is through incident reports, and these are now being collected in an organized fashion through the Radiation Oncology Incident Learning System (RO-ILS), sponsored by ASTRO and AAPM (14). The program has experienced a steady growth in both number of participants and use of the system.…”

Section: Big Data Resources Currently Available And/or In Developmentmentioning

confidence: 99%

Overview of the American Society for Radiation Oncology–National Institutes of Health–American Association of Physicists in Medicine Workshop 2015: Exploring Opportunities for Radiation Oncology in the Era of Big Data

Benedict

Hoffman

Martel

et al. 2016

International Journal of Radiation Oncology*Biology*Physics

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“…Incident learning systems are a key component of safety culture in the medical field . The Radiation Oncology Incident Learning System (RO‐ILS) is an incident learning system sponsored by both ASTRO and AAPM which enables users to submit radiation oncology‐related incidents to a national database . With this database, RO‐ILS is able to review large numbers of events and provide education to clinics on the types of incidents reported via quarterly reports and case studies.…”

Section: Introductionmentioning

confidence: 99%

“…[1][2][3][4][5] The Radiation Oncology Incident Learning System (RO-ILS) is an incident learning system sponsored by both ASTRO and AAPM which enables users to submit radiation oncology-related incidents to a national database. 6,7 With this database, RO-ILS is able to review large numbers of events and provide education to clinics on the types of incidents reported via quarterly reports and case studies. RO-ILS can also serve as an institution's primary ILS for review and management of incidents.…”

Section: Introductionmentioning

confidence: 99%

Technical Note: Use of automation to eliminate shift errors

Covington

Popple

Cardan

2020

J Applied Clin Med Phys

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Purpose To create automated tools within the treatment planning system (TPS) that eliminate the common error pathway of providing incorrect shift instructions to therapists. Materials/Methods Two scripts were created within the TPS using the Eclipse API (Varian Medical Systems, Palo Alto, CA). One script detects whether or not the user origin has been placed correctly at the intersection of the simulation markers while the other calculates a shift instruction sheet that can be printed for treatment. Results Analysis of our RO‐ILS database identified eight errors caused by improper setting of the user origin in the treatment planning system. The user origin script flagged all of the treatment plans for markers inconsistent with user origin. Automated calculation of shifts eliminated the error pathway of miscalculating or transcribing shift values. Conclusion Automation can eliminate the common error pathway of providing the wrong shifts to therapists. The scripts have been made available as open‐source software for implementation at other radiotherapy clinics.

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

Cited by 73 publications

References 15 publications

A patient safety education program in a medical physics residency

A patient safety education program in a medical physics residency

Overview of the American Society for Radiation Oncology–National Institutes of Health–American Association of Physicists in Medicine Workshop 2015: Exploring Opportunities for Radiation Oncology in the Era of Big Data

Technical Note: Use of automation to eliminate shift errors

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