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    1 Makelle Barski 518 Professional Issues October 6, 2019 RO-ILS Case Study With the radiation oncology field constantly evolving, field sizes are getting smaller with dose escalation to produce a stronger biological effect on the tumor with less dose to the surrounding normal tissue. This makes it vital to deliver radiation accurately for the safety of our patients. Overdosing or treating the wrong site can cause toxicity in  patients. The World Health Organization (WHO) and International Atomic Energy Agency (IAEA) stated that from 1976 to 2007, 3,125 patients were affected by radiation therapy (RT) incidents that led to adverse events. 1  The United States Nuclear Regulatory Commission (NRC) states that about more than 60% of errors are due to human error. 2  Other errors in radiation oncology include technologic errors, so having continuous quality improvement and quality assurance programs need to be put in place and closely monitored to improve patient quality of care. In June 2011, the American Society for Radiation Oncology (ASTRO) in  partnership with the American Association of Physicists in Medicine (AAPM) developed Radiation Oncology Incident Learning System (RO-ILS) to promote shared learning of incidents across all institutions. 3  RO-ILS presents incident case studies that we can learn from to prevent future errors from occurring. One case study involves a patient being treated to the wrong site for 1 out of 45 fractions. The patient was aligned to the stereotactic body fix system using tattoos that were in a 3 point alignment. The therapist made the daily shift from the tattoo to the isocenter. The stereotactic system requested a 2.5 cm shift longitudinally. A cone beam computed tomography (CBCT) scan was done and a 0.4 cm shift was made in the superior/inferior direction. This made a total shift of 2.1cm. A physician reviewed the CBCT later, in an offline review, and caught that the therapists treated the wrong vertebral body. We can analyze this case to see what contributed to the mistreat and solutions to prevent errors like these from happening again. While reducing errors in radiation oncology should be a simple process, the reality is that it is a multistep process. 4  There is a multidisciplinary team that contributes    2 to every single treatment. A treatment plan starts with making sure the patient’s  pathology is correct and if the prescription to the disease is appropriate. A CT simulation is then performed to get the patient in a desirable treatment position and to place the isocenter. At this point, it is important to document set-up photos and take measurements of the tattoos so that the therapists can align the patient accurately for treatment. Ideally, the physician would place the isocenter in a stable spot and, if possible, where the tattoos will be. If a shift does not have to be made, we should avoid it as long as the dosimetrists can plan it (keeping it not too close to a block edge). If dosimetry plans it and there needs to be a shift, the shift should be documented in the site set-up as well as a measurement indicating the shift in the plan. When therapists treat the patient, pictures of the tattoos should be reviewed and measurements of the tattoo should be taken. Correct patient devices used for treatment should also be verified. The shift should always be stated out loud so other therapists can double check it. We should not always rely on technology such as CBCT and make sure what we are looking at makes sense. We should double check the we have the correct patient on the CBCT and that we used the correct CBCT technique when we scan patients. CBCT should be checked every morning before treatments for quality assurance. Any of these errors in this chain of events before a  patient gets treated can contribute to an incident that can cause adverse effects. It is policy in our department to take an orthogonal set of port films to double check the CBCT. This policy has caught the CBCT being off by one vertebral body in the  past and could have prevented this situation. A physician is always required to view both  port films and CBCT the first fraction prior to treatment as well. In the event that this was not the first fraction, if the patient had over a 1 cm shift, and the CBCT looked off, we would reset the patient and double check everything (patient devices, tattoos, shifts, correct CBCT). In the event that the patient was still over a 1 cm shift, a physicist or a  physician would be called to make sure the CBCT is sufficient and to continue with treatment. Having policies in place like these will create more good catches to near-misses instead of incidents. Errors in the medical field are inevitable, but we can put quality assurance checklists and policies in place to minimize them. It is important to acknowledge near-misses and establish a safety culture where the multidisciplinary team can comfortably    3 identify these problems or potential problems, learn from them, take action, and evaluate the effectiveness. Safety is our number one responsibility for these patients.    4 References 1. World Health Organization (WHO). Radiotherapy Risk Profile. 2008. Geneva. 2. Duffey RB, Saull JW. Know the Risk- Learning from Errors and Accidents: Safety and Risk in Today’s Technology. Oxford, United Kingdom: Butterworth -Heinemann 2002. 3. RO-ILS Background - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO). ASTRO. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/RO-ILS/RO-ILS-Background. Accessed October 4, 2019. 4. Sternick ES. Development of a comprehensive radiation oncology quality and safety  program.  Front Oncol  . 2014;4:30.
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