Here we go again: Trends and Common Error Pathways in the RO-ILS system

Document Type

Conference Proceeding

Publication Date

9-30-2025

Publication Title

Med Phys

Keywords

collaborative learning, conference abstract, dose calculation, female, human, learning, male, physicist, radiation oncologist, radiation oncology, radiotherapy, safety culture, workflow

Abstract

Since 2014, AAPM and ASTRO have partnered to manage the national Radiation Oncology Incident Learning System: RO-ILS, a data-driven program free to users that supports the identification of errors and a culture of continuous improvement. With over one-third of all facilities in the US now enrolled, and over 40,000 reports submitted, the RO-ILS system offers a rich resource for shared learning to improve the field of radiation oncology. The AAPM Workgroups on RO-ILS and RO-ILS's Radiation Oncology Healthcare Advisory Council have collaborated on this session as another mechanism to share the latest aggregated findings. There will be a well-rounded, diverse panel which includes senior physicists, radiation oncologists, an early career physicist, and a RO-ILS 2023 physics safety star. Two current representatives of the Radiation Oncology Healthcare Advisory Council will share overall trends and error pathways and then focus on high impact contributing factors and specific problem types such as wrong treatment site and dose calculation error. The panel discussion will suggest high-yield mitigation strategies, and invite the audience to contribute their own. Additionally, a RO-ILS user will share their own experience with engaging the entire team in incident learning to promote a positive safety culture. Attendees will leave the session with tools to forge ahead in elevating their local incident learning and process improvement to maximize the advancement of safety. Learning Objectives: 1. Understand common error pathways in radiation oncology physics, drawn from over 40,000 reports in the AAPMsupported RO-ILS system. 2. Identify mitigation strategies to improve workflows and team collaboration. 3. Develop tools to increase incident learning engagement and safety culture, thus empowering all team members to improve quality and safety.

Volume

52

Issue

10

First Page

12

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