10 Years of RO-ILS:
Collaboration and Improvement for Patient Safety
Ksenija Kujundzic
Senior Manager, Quality Improvement
ASTRO
Given the technical sophistication of radiation therapy, each member of the clinical team has specialized responsibilities and makes valuable contributions to patient care. It is this team-driven environment that helps heighten the quality and safety of patient care. ASTRO’s quality programs, APEx - Accreditation Program for Excellence® and Radiation Oncology Incident Learning System (RO-ILS®), leverage collaborative teamwork to propel process-driven improvement. This June marks 10 years of operation for RO-ILS, a program built around collaboration and bringing teams together to benefit patient safety.
More than a decade ago, ASTRO and the American Association of Physicists in Medicine partnered to develop RO-ILS. The three aims of this national program are to (1) offer a secure mechanism for error reporting, (2) foster a non-punitive environment and (3) facilitate safer and higher quality care.
First aim: In 2005, a law creating patient safety organizations (PSOs) enabled collection of medical error information in a protected and confidential environment. ASTRO contracted with an established PSO to provide the associated services and reduce concerns about collecting and sharing sensitive information. While specialty agnostic PSO work has become more commonplace, especially in hospitals, the existence of a specialty-specific program of this sophistication is rare.
Second aim: The opposite of a “shame and blame” environment is a strong safety culture that is transparent, fair and where staff are accountable but not punished. To promote a workplace without fear of retribution, staff at the 850+ facilities enrolled in RO-ILS can anonymously report a safety event. RO-ILS education serves as an example of how to share and discuss safety events with safety culture in mind; it does not point fingers or identify users but rather focuses on environment-related contributing factors and process-driven mitigation strategies. Positive reinforcement also helps counter apprehension about disclosing errors. With this in mind, in 2022 RO-ILS began publishing multiple great catch events to celebrate different radiation oncology team members generally, and in 2023, started recognizing specific individuals as safety stars.
Third aim: The primary mechanism of facilitating safer care and disseminating shared learning is RO-ILS education. A small group of safety experts known as the RO-HAC work with the PSO to analyze and share findings from RO-ILS data. Starting with quarterly reports and evolving to multiple resources, RO-ILS has released more than 60 written educational reports (see astro.org/roilsreports), many of which have reached international audiences. Themed reports on topics like peer review, surface guidance, and training have identified trends in a RO-ILS aggregate database now comprising over 37,000 safety events! RO-ILS fosters teamwork by including safety check questions in RO-ILS education to facilitate group discussion and hosting interactive events for all clinical team members such as a recent virtual discussion about select RO-ILS events. Together, all this work affords individuals, teams and the field an opportunity to proactively address the risk of errors.
In the first decade of RO-ILS, ASTRO invested in extensive development and standardization of radiation oncology-specific data collection, advancements in safety trend analysis and overall increased outreach to radiation oncology facilities. This work could not be done without:
- Sponsors and supporters who help finance this work.
- Safety advocates who pushed for the adoption and use of the RO-ILS platform.
- Every person who has submitted and/or reviewed an event for RO-ILS.
- RO-HAC members and volunteers who developed the taxonomy, program materials, etc.
- People and teams who read and leverage RO-ILS education.
