Radiation oncology has something in common with “America’s Got Talent.” A recent episode of the hit show featured a clip of a knife thrower in rehearsal, methodically hurling blades at his wife who was strapped to a turning backboard. Each knife hit its target with precision until the equipment failed. The backboard came loose; his wife fell forward. Tragedy might have struck had a steel edge been flying through the air at that moment.
Equipment failures can strike in the radiation oncology suite as well. While the lion’s share of radiation therapy provides life-saving care on a spectacular level, even great competence travels an uncertain flight path. Ask Adam Dicker, MD, PhD, professor and chair of the Department of Radiation Oncology at Sidney Kimmel Medical College and Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia.
“Do errors occur in radiation oncology? Of course they do. Some have been terrible,” he answered candidly. “They don’t happen often, but when they happen they can be horrific. I remember hearing about a case in which a patient received three times the dose of radiation that was intended.”
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Dicker makes the point that even the most precisely thrown radiologic “knife” can miss its mark. “Could it be human error? Sometimes, yes. But there are technological errors that can occur as well; there can be miscommunication between the equipment delivering the dose and the computer controlling it. From the initial planning of the dose to the actual delivery of the dose, there are myriad opportunities for error,” he said.
It’s not Dicker’s intention to indict his colleagues or throw an entire discipline under the bus. To the contrary, Dicker is hell-bent on throwing them an error-reporting lifeline when mistakes happen – as they clearly do.
Until very recently, errors in the radiation oncology suite at any given facility were largely kept under wraps and known only to that facility and its vendors. “Let’s say a team discovers a flaw between their software and hardware, with a potential for delivering an incorrect dose to a patient,” said Dicker hypothetically. “That team will go back to the vendors – each of which will point the finger of blame at the other. But where do they go next? Who do they call to make sure no other facility faces the same potential for patient harm? How do they get the word out?”
Dicker said the answer to that question is complicated. “Think it’s just a call to the FDA? No way. There are more than 20 federal-level agencies that come into play in a situation like this,” he explained. Furthermore, if a team publicly reveals a problem that did indeed result in incorrect dosing or patient harm, it opens itself and its facility up to the potential for a lawsuit and a costly legal battle. “It kills the incentive to speak up. Their hands are tied,” said Dicker.
What’s the Solution?
In 2011, the American Society for Radiation Oncology (ASTRO) surveyed its membership on the issue of error reporting, said Dicker. “The survey revealed that 85% of radiation oncologists and 94% of medical physicists would use a confidential reporting system for medical errors and near misses. The problem was, none existed.”
Enter RO-ILS: Radiation Oncology Incident Learning System, launched in 2014. RO-ILS is a federally protected space that was created through the cooperative efforts of ASTRO, the American Association of Physicists in Medicine (AAPM) and Clarity PSO, a patient safety organization. Dicker, who serves on the national advisory board for RO-ILS, explained that it is a PSO set up under strict federal guidelines. Practitioners who voluntarily choose to use the confidential reporting platform enter into a contractual agreement with the PSO that provides for the manner of its use.
Dicker explained, “Participants use an electronic, web-based tool to submit information through Clarity PSO’s Healthcare SafetyZone Portal. There they can enter information about misadministration errors, close calls, good catches and near misses. things that may or may not have caused harm. The beauty is everyone is de-identified and their information is safe and protected from investigation by malpractice lawyers.”
Dicker, who co-authored a report on the first year of RO-ILS in the journal Practical Radiation Oncology,1 noted there are now more than 200 facilities using the confidential reporting platform. In the report, he wrote that in the first year 739 patient-safety events had been entered into local databases. Of those events, 48% were further shared on a national database for analysis by the Radiation Oncology Healthcare Advisory Council, which found that most errors occurred in the pretreatment review/verification steps of therapy – useful and actionable knowledge for all working in radiation oncology.
Dicker believes that having a means to report errors without fear of recrimination is essential to improving quality and safety throughout the field of radiation oncology and healthcare. “RO-ILS participants are finding their voices, and they are using them to benefit everyone. Reporting efforts are consistent, clear and growing. We have taken an important step forward in improving quality and safety for our patients.”
Valerie Newitt is on staff at ADVANCE. Contact: email@example.com.
1: Hoopes, D.J. et al. RO-ILS: Radiation oncology incident learning system: A report from the first year of experience. Practical Radiation Oncology. 2015;5:312-318.