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RO-ILS Safety Notice

The mission of the RO-ILS: Radiation Oncology Incident Learning System® 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. Recognizing that much can be learned from a variety of events, RO-ILS allows for widespread dissemination of de-identified information to educate the radiation oncology community. Prior to the implementation of RO-ILS, the community was only privy to public records from very severe safety events. Yet much can be learned from all variety of events, including errors caught before reaching the patient and events that do not meet the threshold for mandatory external reporting.

Clarity PSO provides the affiliated patient safety services outlined in the Patient Safety and Quality Improvement Act of 2005, including the confidentiality and privilege protections, to practices enrolled in RO-ILS. Safety events voluntarily entered into RO-ILS and then reported to Clarity PSO are analyzed, triaged and, where warranted, reviewed by members of the Radiation Oncology Healthcare Advisory Council (RO-HAC). The RO-HAC is an interdisciplinary group of healthcare professionals, including radiation oncologists, physicists, dosimetrists, therapists and an administrator, who provide subject-matter expertise on data interpretation and reporting and suggest possible interventions. The RO-HAC operates as part of Clarity PSO's patient safety evaluation system and is not subject to either ASTRO or AAPM review or oversight.

During the review of events reported to the PSO, RO-HAC may identify an event worthy of escalated status and determine that a Safety Notice is warranted. A RO-ILS Safety Notice communicates findings that may be novel to the community, of higher clinical significance, and/or deserve more prompt review.

ROILS Safety Notice

RO-HAC determined that a recent event related to stereotactic radiosurgery heterogeneity corrections warranted a Safety Notice because the systematic errors affected multiple patients and was difficult to detect. This RO-ILS Safety Notice includes a description of the error, contributing factors, lessons learned for the radiation oncology community and considerations for medical equipment and software vendors. To read the notice, click on the image to the right. 

(Page last updated April 1, 2020.)
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