Radiation Oncology Incident Learning System: A Call to Participation

Abstract

In the wake of news media reports in 2010 of several tragic incidents of radiation error resulting in substantial harm (1), the leadership of American Society for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine (AAPM) testified before congress, and ASTRO initiated the Target Safely program campaign designed to improve the quality and safety of care in radiation oncology. As part of this initiative, ASTRO, with the support of AAPM, committed to a national error reporting system and safety database. On June 19, 2014, this campaign debuted the Radiation Oncology Incident Learning System (RO-ILS). For such a system to be successful, several requirements must be met. First and foremost, the information must be protected in order for an open and honest discussion to occur. Fortunately, there is a mechanism for such protection under U.S. law. It is called the patient safety organization (PSO). PSOs were established in 2005 as part of the Patient Safety and Quality Improvement Act. ASTRO and AAPM have paired with a federally listed PSO, Clarity PSO, to form a specialty-specific PSO. This will provide a nonpunitive environment in which to assemble and analyze data, thereby protecting data from discovery, subpoena, order, or disclosure under the Freedom of Information Act. This is a federal protection, and it was designed specifically to encourage institutions to engage in incident learning. These protections have been tested in Kentucky (Norton Hospitals, Inc. v. Cunningham) and in Illinois (Department of Financial and Professional Regulation v. Walgreen Company). In both cases, the courts found for the institution reporting to the PSO, and PSO protections were upheld.