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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:

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.

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. 

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.

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.

TimeframeTopics/ThemesReportCME
Third-Fourth Quarter 2018
  • Vertebral Body Alignment
  • HDR Treatment Length and Dwell Times
  • Patient Identification and Communication
Q3, Q4 2018CME
First-Second Quarter 2018
  • Treatment planning
  • Hand-offs
Q1, Q2 2018CME
Fourth Quarter 2017
  • Human factors engineering
  • Contouring
  • Results from prescription survey
Q4 2017CME
Third Quarter 2017
  • Difference between physician’s intent and dosing patterns used
  • Emergency, on-call treatments
  • Value of speaking up
Q3 2017CME
Second Quarter 2017
  • SBRT
  • Process improvement (DMAIC)
Q2 2017CME
First Quarter 2017
  • Errors at the time of treatment
  • Contributing Factors
Q1 2017CME
Fourth Quarter 2016
  • RO-HAC triage and severity assessment
  • Electron beam
  • Best practice: event reporting and implementing change
Q4 2016CME
Third Quarter 2016
  • Policies and procedures
  • IGRT/set-up
  • Prescription
Q3 2016CME
Second Quarter 2016
  • Treatment delivery to the wrong target
  • Communication
Q2 2016 
First Quarter 2016
  • HDR
  • Laterality, manual data entry, patient orientation
  • Approved plan different from intent
  • Occurrence and discovery of errors within the workflow process
Q1 2016 
Fourth Quarter 2015
  • Rushes cases
  • Changes to the course of therapy
  • Missed treatments and prescriptions
  • Physician’s prescription does not match care intended/delivered
  • Overall characterization of event types
Q4 2015 
Third Quarter 2015
  • Importance of review
  • Incorrect isocenter
  • Time-outs
Q3 2015 
Second Quarter 2015
  • Summary of unsafe conditions, near misses, and incidents
  • RO-ILS report as a training tool
Q2 2015 
First Quarter 2015
  • Communication
  • Prescription
  • Planning on wrong scan set
Q1 2015 
Fourth Quarter 2014
  • Summary of incidents with medical impact
  • Distraction, multi-tasking and interruptions
Q4 2014 
Third Quarter 2014
  • Incidents with >5% dose deviation
  • Time-outs
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":

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