RO-ILS Education
A variety of RO-ILS education is posted on the RO-ILS website to facilitate shared learning across the field of radiation oncology.
Safety Notice
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. For more information, read the Safety Notice on stereotactic radiosurgery heterogeneity corrections.
Themed Reports
RO-HAC is developing reports that transcend the entire RO-ILS database focused on various topic areas:
- COVID-19 Disruption to Processes
- Peer Review
- Surface Guided Radiation Therapy
- Training and Education
- Equipment QA
- Dosimetrically Impactful Events
- Rushing and/or Scheduling
Case Studies
Starting in 2018, RO-ILS began releasing RO-ILS case studies. These stand-alone case studies summarize a RO-ILS event and provide learning, feedback and suggestions from RO-HAC. When possible, RO-ILS seeks to engage the practice that reported the event in an open dialogue and development of the case study. With Clarity PSO working as an intermediary, practices who agree to collaborate are always given the option to remain anonymous.
- Case Study 01: Error in Scheduling Patient Treatment
- Case Study 02: Adaptive Planning
- Case Study 03: Incorrect Density Factor
- Case Study 04: SRS Heterogeneity Correction and Commissioning
- Case Study 05: COVID-19 and CT Imaging
- Case Study 06: Insufficient Imaging for Set-up
- Case Study 07: Prior Spinal Radiation Missed
- Case Study 08: IT Permissions Disrupt HDR Delivery
- Case Study 09: What's In a Name: Use of Functional Conventions to Aid the Second Check ("Good Catch Case")
- Case Study 10: Contour Delineation
- Case Study 11: Adjacent Isocenters and Timeouts
- Case Study 12: Is That a Pacemaker Near the Treatment Volume?
- Case Study 13: Adherence to Process: Pitfalls in Redundant Communication Pathways
- Case Study 14: Understanding the Limitations of a Plan Sum
- Case Study 15: Brachytherapy Applicator Digitalization
- Case Study 16: Prescription Transcription Error and Incorrect MUs
- Case Study 17: Make Time for Timeouts!
- Case Study 18: Pictures Worth a Thousand Words
- Case Study 19: Wrong Vertebral Body Alignment Using Auto-Registration for SBRT
Great Catches
In order to promote a strong culture of safety, it is important to celebrate patient safety work and the radiation oncology team. To celebrate various members of the team, RO-ILS releases great catches and identifies safety stars. RO-ILS encourages all practices to identify ways to thank and recognize staff year around, but especially on their honorary day. Nominations for safety stars are accepted year round.
- March 30, 2024: Doctors' Day
- August 21, 2024: National Medical Dosimetrist's Day
- 2024 Dosimetry Safety Stars
- 2024 RO-ILS Great Catch
- 2023 Dosimetry Safety Stars
- 2023 RO-ILS Great Catch
- 2022 RO-ILS Great Catch
- November 3-9, 2024: National Radiologic Technology Week
- 2023 Therapist Safety Stars
- 2023 Therapy Great Catch
- 2022 RO-ILS Good Catch
- November 7, 2024: International Day of Medical Physics
- 2023 Physicist Safety Stars
- 2023 Physics Great Catch
- 2022 RO-ILS Good Catch
Five Years of Experience Program Report
The RO-ILS in Review: First Five Years of Experience Report describes accomplishments and programmatic changes (e.g., new data elements, new internal triage mechanism for event review by RO-HAC) as well as the importance of internal event review. It also provides important background information, an overview of the submission and reporting process and program benefits.
Aggregate Data Reports
These reports provide a high-level look at the trends in the national database and include a “report card” and graphs. Reports are released quarterly and supplement the RO-HAC commentary provided in the case studies, themed reports and other educational offerings.
- Q2 2024
- Q1 2024
- Q4 2023
- Q3 2023
- Q2 2023
- Q1 2023
- Q4 2022
- Q3 2022
- Q2 2022
- Q1 2022
- Q4 2021 - ASTRO Blog post comments on a new 2021 trend related to where in the workflow the error occurred.
- Q3 2021
- Q2 2021
- Q1 2021
- Q4 2020
Published Manuscripts
"A Report from the First Year of Experience," written by RO-HAC and staff, was published in the September-October 2015 Safety Issue of Practical Radiation Oncology (PRO). To learn more about the full process from conception to beta testing and finally operation, read the 2015 PRO article.
"Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety," written by RO-HAC, was published in the March-April 2018 Issue of PRO. To learn more about the common patterns for the more severe events reported in RO-ILS, read the 2018 PRO article.
Quarterly/Bi-Annual Reports (2014-2018)
These reports, developed during the first few years of the program, provide insight on patient safety in the form of a summary report card, case reviews and detailed commentary. As the program has grown and matured, the frequency and format of education has evolved. Initially, these reports were released quarterly and then biannually before they were separated into the new educational offerings (aggregate data reports, case studies, themed reports, etc.). Beginning with the Third Quarter 2016 report, ASTRO began offering associated continuing medical education.
Timeframe | Topics/Themes | Report | CME |
---|---|---|---|
Third-Fourth Quarter 2018 |
| Q3, Q4 2018 | CME |
First-Second Quarter 2018 |
| Q1, Q2 2018 | CME |
Fourth Quarter 2017 |
| Q4 2017 | CME |
Third Quarter 2017 |
| Q3 2017 | CME |
Second Quarter 2017 |
| Q2 2017 | CME |
First Quarter 2017 |
| Q1 2017 | CME |
Fourth Quarter 2016 |
| Q4 2016 | CME |
Third Quarter 2016 |
| Q3 2016 | CME |
Second Quarter 2016 |
| Q2 2016 | |
First Quarter 2016 |
| Q1 2016 | |
Fourth Quarter 2015 |
| Q4 2015 | |
Third Quarter 2015 |
| Q3 2015 | |
Second Quarter 2015 |
| Q2 2015 | |
First Quarter 2015 |
| Q1 2015 | |
Fourth Quarter 2014 |
| Q4 2014 | |
Third Quarter 2014 |
| Q3 2014 |
Participating practices receive biannual reports with practice-level data.
RO-HAC
The Radiation Oncology Healthcare Advisory Council (RO-HAC) is a group of radiation oncology professionals who provide subject-matter expertise, including helping Clarity PSO analyze, interpret and report on data submitted into RO-ILS. RO-HAC members include radiation oncologists, physicists, dosimetrists and other patient safety experts. Members of RO-HAC receive an honorarium and must sign a contract with Clarity PSO before accessing any data. 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.
Announcements
RO-ILS participants receive regular emails (previously known as "Tips of the Month") with program information, suggestions and reminders. Previous announcements have included RO-ILS specific information including best practices for tracking trends internally and a guide to utilizing the Analysis Wizard in the RO-ILS portal. Additionally, these announcements educate users on the broader scope of patient safety and incident learning including how to write a comprehensive narrative and understanding patient safety work product (PSWP). Below, please find some examples of broadly-applicable "Tips of the Month":