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Sep 28
Education

EDU 25 - Closing the Safety Loop: Translating RO-ILS Lessons into Practical QA Safeguards, Workflow Guardrails and Safer Software

03:00pm - 04:00pm ET
Patient Safety and Quality
Practical Radiation Oncology

MODERATOR(S)

Suzanne Evans, MD, FASTRO - Yale University School of Medicine

session DESCRIPTION

With over 50,000 event reports after 10 years, the RO-ILS system provides a rich, real-world foundation for improving safety in radiation oncology. This interactive, vendor-neutral session goes beyond case review by analyzing selected RO-ILS events through a lens that adds practical QA safeguards, workflow guardrails, and system design strategies that multidisciplinary teams can apply across the planning and treatment process lifecycle. It will leverage the wealth of data from the RO-ILS system as well as the Radiation Oncology Safety Stakeholders Initiative (RO-SSI), a fifteen-year-old initiative that includes ASTRO, vendor partners, clinicians and other stakeholders. Three RO-ILS cases will be used as starting points—spanning (1) a mistreatment of a target region in head-and-neck cancer, (2) an IGRT/registration error involving auto-registration to the wrong vertebral level, and (3) a delivery event involving patient-plan mismatch during interrupted timeouts — to map the failure chain, surface key contributing factors, and identify high-yield controls to mitigate a recurrence. The speakers include three experts in quality and safety representing different perspectives of clinical radiation oncology, medical physics and industry software and design expertise. Presentations will include consideration of how industry partners can responsibly use RO-ILS case studies in structured, cross-functional design reviews to teach engineers to improve systems. Audience Response System (ARS) polling will be used to compare how safeguards are implemented across institutions and guide discussion toward broadly applicable approaches. This session builds another very well-received session in 2015, early in the history of RO-ILS, which focused on incident learning and the IHE-RO system.

learning objectives

  1. Appreciate the value of RO-ILS case narratives for identifying safety-critical issues across the chain of the process of care.
  2. Gain familiarity with established quality improvement and error prevention methods informed through the lens of the wealth of data that has emerged from the RO-ILS system.
  3. Differentiate "consistency checks" (systems agree with themselves) from "intent validation" (plan/delivery aligns with prescription and clinical plausibility) and assess where each should be applied in local QA and workflow.

Credits

AMA PRA Category 1 Credits: 1.00

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