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Pinnacle plan verification

OliveTree

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10+ Year Member
Dec 4, 2007
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For those clinics using pinnacle-- how do you ensure the plan you approve is the one finally uploaded for treatment? We rely on our physicists and sign PDF documents in mosaiq for our final approval, but that does not guarantee the right plan/beams are being uploaded & delivered. We might as well be signing a picture of PDF of Micki Mouse.
 

RickyScott

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Oct 4, 2017
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For those clinics using pinnacle-- how do you ensure the plan you approve is the one finally uploaded for treatment? We rely on our physicists and sign PDF documents in mosaiq for our final approval, but that does not guarantee the right plan/beams are being uploaded & delivered. We might as well be signing a picture of PDF of Micki Mouse.
Not a pinnacle user, but at least for imrt, portal dosimetry QA would verify that the right plan was uploaded. For 3D, portal images of all beams is pretty much verifying the right plan was uploaded?
 

scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
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For those clinics using pinnacle-- how do you ensure the plan you approve is the one finally uploaded for treatment? We rely on our physicists and sign PDF documents in mosaiq for our final approval, but that does not guarantee the right plan/beams are being uploaded & delivered. We might as well be signing a picture of PDF of Micki Mouse.
Not for nothing, but this agita isn’t Pinnacle/Mosaiq exclusive. This agita is freely available to us all. In rad onc we “rely on our physicists” and dosimetrists and therapists to an outsize extent versus any other medical specialty relying on non-MDs. The only analogue that’s even close is when an MD writes a script for a drug, and the pharmacist at CVS fills it. Without ANY verification by the script writing MD at all. Ronald Reagan who about the Russians said “Trust, but verify” couldn’t have been a rad onc. The only way an MD could be REALLY sure: personally scan the patient, place skin marks, import CT, do plan, upload to R&V, QA the plan, treat the patient, and perform machine and sim and TPS QA regularly. All personally, by the MD.

Say all that to say this: just sign the PDF, and then go fishing.
 
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ramsesthenice

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Dec 2, 2011
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For those clinics using pinnacle-- how do you ensure the plan you approve is the one finally uploaded for treatment? We rely on our physicists and sign PDF documents in mosaiq for our final approval, but that does not guarantee the right plan/beams are being uploaded & delivered. We might as well be signing a picture of PDF of Micki Mouse.

I feel you but have to agree with Scar on this one. If you are doing IGRT you will verify the iso is right and shifts are reasonable. Beyond that the most you could realistically check in the PDFs is that the MUs and numbers of beams/arcs is correct. I know when I first started that signing plan approvals was easily the worst part of the job. There was (and still is) no reasonable way for me to verify most of what is in the documents.

A lot of this really is out of our hands. Even with the right plan a lot could still go wrong. Physical wedges use to be a common source of error. Use to be a decent number of suits involved therapists using the wrong wedges or worse, forgetting to put the wedge in and delivering 2x the intended dose. You were the one left holding the bag in court but really unless you were physically in the room for each treatment there was no way you could do anything about this beyond trusting your staff. It’s an uncomfortable reality of the job.
 
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RadRadRad

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Aug 24, 2010
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Not for nothing, but this agita isn’t Pinnacle/Mosaiq exclusive. This agita is freely available to us all. In rad onc we “rely on our physicists” and dosimetrists and therapists to an outsize extent versus any other medical specialty relying on non-MDs. The only analogue that’s even close is when an MD writes a script for a drug, and the pharmacist at CVS fills it. Without ANY verification by the script writing MD at all. Ronald Reagan who about the Russians said “Trust, but verify” couldn’t have been a rad onc. The only way an MD could be REALLY sure: personally scan the patient, place skin marks, import CT, do plan, upload to R&V, QA the plan, treat the patient, and perform machine and sim and TPS QA regularly. All personally, by the MD.

Say all that to say this: just sign the PDF, and then go fishing.

finally found solution to job market
All tasks must be done by MD:)
 
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scarbrtj

I Don't Like To Bragg
5+ Year Member
Dec 18, 2015
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finally found solution to job market
All tasks must be done by MD:)
In certain Jerry Maguire-esque moments, I've wanted to write a "The Things We Think and Do Not Say" as to why we don't do all this (to some extent). As much as we bash/honor the past, I think if we were building rad onc from the ground up in 2020 we would not cede as much work/control to non-MDs as we do. Rad onc's traditions come from a very different workflow era, and yet all the traditions and workplace divisions remain. Go and follow a dosimetrist or therapist for a day or two; there's lots of things they're baking in to the treatment process that an MD wouldn't necessarily. Watch a physicist commission a machine or TPS for first use. "Smoothing"... what's that?!

But anyways, just sign the PDF!
 
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Radonc90

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Dec 18, 2004
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@OliveTree,

- If you have great dosimetry/physics staff then I guess you can adopt "scarbrtj's approach" ---> "...just sign the PDF, and then go fishing."

But I think the patients deserve our meticulousness, which is crucial in this field. Anyway, I have discovered the rare errors by CMD/PhD physicists years ago. People are human and to be human is to err.
I have adopted a new approach ---> I hope the following helps you and others:

- Everyday my staff print a day sheet for me with all the patients names on it. You can print it from Mosaiq or Varian Aria system.
Carry this sheet with you at all time during the day.

- Let's say:

1. Mr. John Doe has brain mets from lung ca. You reviewed:
a. Opposed laterals (90 + 270 degrees)
b. RAO (87 degrees) and LAO (273 degrees) to avoid the lenses.
Let's say you like plan "b" better, write it down on your day sheet "87/273" or something like that.
A few days later the PDF is uploaded into Mosaiq or Varian Eclipse, all you have to do is verify it against what you wrote down
and that is it.

2. Mrs. Jane Doe has colon ca met to left hip. You reviewed:
a. AP/PA 23 MV
b. AP/PA 6 MV
Let's say you like plan "a" with 23 MV photons better, write it down on your day sheet "23".
These are code words that only you/your residents understand.

3. IMRT, VMAT is much harder to track, please read on. You reviewed:
a. 8-field static IMRT, let's say spinal cord PRV mean dose is 4345 cGy.
b. VMAT, let's say spinal cord PRV mean dose is 4305 cGy.
Let's say you like plan "b" better.
Just write down on your sheet "sp cord 4305".
When you check the PDF a few days later, if you see spinal cord PRV mean dose = 4345 cGy, and if you check it against your day sheet, you will know something is wrong, i.e., the wrong plan was uploaded.

Most staff know to delete the other "non-approved" plans ASAP and keep only the plan you approved, but humans are humans, we err a bit.
So the way to protect the patients/yourself is to use this little trick I call "dosing signature", which is the "fingerprint" of the approved plan.
Next time you evaluate different plans, you will see spinal cord, heart, lung doses are slightly different a bit from plan to plan.

Let's say you evaluate a lung ca patient dosimetry with 3 plans (a, b, c). Let's say you like plan "c".
Immediately write down the "dosing signature", let's say plan "c" has a mean heart hose of 4506.7895 cGy.
Write it down as "4506.7895 cGy", which must match with the uploaded PDF.
It is virtually impossible for plans "a" and "b" to have the same exact figures of "4506.7895 cGy".

Anyway, this is my trick and it has helped me tremendously...
 
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elementaryschooleconomics

The Salvador Dalí of Dose Painting
Nov 2, 2019
1,354
5,612
76
  1. Attending Physician
@OliveTree,

- If you have great dosimetry/physics staff then I guess you can adopt "scarbrtj's approach"... "...just sign the PDF, and then go fishing."
But I think the patients deserve our meticulousness, which is crucial in this field. Anyway, I have discovered the rare errors by CMD/PhD physicists years ago. People are human and to be human is to err.
I have adopted a new approach ---> I hope the following helps you and others:

- Everyday my staff print a day sheet for me with all the patients names on it. You can print it from Mosaiq or Varian Aria system.
Carry this sheet with you at all time during the day.

- Let's say:

1. Mr. John Doe has brain mets from lung ca. You reviewed:
a. Opposed laterals (90 + 270 degrees)
b. RAO (87 degrees) and LAO (173 degrees) to avoid the lenses.
Let's say you like plan "b" better, write it down on your day sheet "87/173" or something like that.
A few days later the PDF is uploaded into Mosaiq or Varian Eclipse, all you have to do is verify it against what you wrote down
and that is it.

2. Mrs. Jane Doe has colon ca met to left hip. You reviewed:
a. AP/PA 23 MV
b. AP/PA 6 MV
Let's say you like plan "a" with 23 MV photons better, write it down on your day sheet "23".
These are code words that only you/your residents understand.

3. IMRT, VMAT is much harder to track, please read on. You reviewed:
a. 8-field static IMRT, let's say spinal cord PRV mean dose is 4345 cGy.
b. VMAT, let's say spinal cord PRV mean dose is 4305 cGy.
Just write down on your sheet "spc 4305".
When you check the PDF a few days later, let's say if you see spinal cord PRV mean dose = 4345 cGy, you check it against your sheet, and you will know something is wrong.

Most staff know to delete the other plans ASAP and keep only the plan you approved, but human are human, we err a bit.
So the way to protect the patients/yourself is to use this little trick I call "dosing signature", which is the "fingerprint" of the approved plan.
Next time you evaluate different plans, you will see spinal cord, hear, lung doses are slightly different a bit.

Let's say you evaluate a lung ca patient dosimetry with 3 plans (a, b, c). Let's say you like plan "c".
Immediately write down the "dosing signature", let's say plan "c" has a mean heart hose of 4506.7895 cGy.
Write it down as "4506.7895 cGy", which must match with the uploaded PDF.
It is virtually impossible for plans "a" and "b" to have the same exact figures of "4506.7895 cGy".

Anyway, this is my trick and it has helped me tremendously...

Wow, I might steal this...
 
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evilbooyaa

Full Member
Staff member
Volunteer Staff
7+ Year Member
Oct 10, 2011
7,256
7,824
326
  1. Attending Physician
@OliveTree,

- If you have great dosimetry/physics staff then I guess you can adopt "scarbrtj's approach" ---> "...just sign the PDF, and then go fishing."

But I think the patients deserve our meticulousness, which is crucial in this field. Anyway, I have discovered the rare errors by CMD/PhD physicists years ago. People are human and to be human is to err.
I have adopted a new approach ---> I hope the following helps you and others:

- Everyday my staff print a day sheet for me with all the patients names on it. You can print it from Mosaiq or Varian Aria system.
Carry this sheet with you at all time during the day.

- Let's say:

1. Mr. John Doe has brain mets from lung ca. You reviewed:
a. Opposed laterals (90 + 270 degrees)
b. RAO (87 degrees) and LAO (273 degrees) to avoid the lenses.
Let's say you like plan "b" better, write it down on your day sheet "87/273" or something like that.
A few days later the PDF is uploaded into Mosaiq or Varian Eclipse, all you have to do is verify it against what you wrote down
and that is it.

2. Mrs. Jane Doe has colon ca met to left hip. You reviewed:
a. AP/PA 23 MV
b. AP/PA 6 MV
Let's say you like plan "a" with 23 MV photons better, write it down on your day sheet "23".
These are code words that only you/your residents understand.

3. IMRT, VMAT is much harder to track, please read on. You reviewed:
a. 8-field static IMRT, let's say spinal cord PRV mean dose is 4345 cGy.
b. VMAT, let's say spinal cord PRV mean dose is 4305 cGy.
Let's say you like plan "b" better.
Just write down on your sheet "sp cord 4305".
When you check the PDF a few days later, if you see spinal cord PRV mean dose = 4345 cGy, and if you check it against your day sheet, you will know something is wrong, i.e., the wrong plan was uploaded.

Most staff know to delete the other "non-approved" plans ASAP and keep only the plan you approved, but humans are humans, we err a bit.
So the way to protect the patients/yourself is to use this little trick I call "dosing signature", which is the "fingerprint" of the approved plan.
Next time you evaluate different plans, you will see spinal cord, heart, lung doses are slightly different a bit from plan to plan.

Let's say you evaluate a lung ca patient dosimetry with 3 plans (a, b, c). Let's say you like plan "c".
Immediately write down the "dosing signature", let's say plan "c" has a mean heart hose of 4506.7895 cGy.
Write it down as "4506.7895 cGy", which must match with the uploaded PDF.
It is virtually impossible for plans "a" and "b" to have the same exact figures of "4506.7895 cGy".

Anyway, this is my trick and it has helped me tremendously...

Interesting technique. Might be stealing this.
 
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