ASTRO's Radiation Oncology-Incident Learning System (RO-ILS): A Multi-site, Multi-faculty Radiation Department Culture Immersion into RO-ILS

Abstract

The Radiation Oncology-Incident Learning System (RO-ILS) is a web based incident reporting system that provides a global mechanism for collaborative learning within radiation oncology. The RO-ILS mission encourages all members to report events as they happen in the department in a non-punitive environment. In September 2017, our multi-site radiation oncology department converted completely to RO-ILS following a decade of usage of an in-house system. The purpose of this work is to share our preliminary experience with RO-ILS, specifically focusing on comparative trends in event reporting, classification and learning. Between October 2017 and January 2018, events submitted were classified into the following categories: Therapeutic radiation incident, other safety incident, near-miss, unsafe condition, operational/process improvement. A single RO-ILS coordinator reviewed and further characterized these events into the following sub-categories for more detailed analysis and follow up. A multi-disciplinary quality management (QM) team met biweekly to investigate and develop follow-up actions which were communicated to the entire staff at monthly meetings at each geographical site to “close the loop” and demonstrate the effectiveness of event reporting. In a 4-month time period, staff reported 325 events. The distribution of events was as follows: Therapeutic radiation incident (53), Other Safety incident (10), Near-miss (19), Unsafe condition (5), and Operational/Process Improvement (238). Due to the default categories being too shallow, events were reclassified into: Communication, Prescription and Directive mismatch, Film Review, Re-simulation, New Plan, On Treatment Visit, Dosimeter, Physics, Equipment Malfunction, Information Technology, Patient on Break, Consent, No physicist on site, Patient Safety, Treatment terminated, Physics weekly chart checks not completed, Pathology, SOARIAN error, Scheduling, and Accident. Event reporting systems serve as an important function in raising awareness and generating a culture of safety. To date, our department has successfully and effectively rolled out RO-ILS and its key components. However, meaningful expansion of default classifications are recommended. RO-ILS allows our team to “track and trend” events, identify root causes, and implement targeted changes to improve patient care. We have provided feedback to the front lines monthly, closing the loop and encouraging further reporting. The frontline staff feels as though their reporting makes a difference, effecting positive changes in the department. As one of the few large multi-site institutions to fully implement RO-ILS, the amount of entries and expanded classifications submitted will provide valuable feedback to the radiation oncology community.