The software deployed in our department to subserve the Record and Verify function for the linear accelerator (linac) is MOSAIQ (Elekta, Mountain View, CA) This software records all of the treatment-related information (eg, beam angle, monitor units, and so on) and compares it with the desired values based on the treatment plan. Treatment is not permitted to commence until all actual and desired values are in agreement and verified. Once the treatment is delivered, MOSAIQ records the parameters of the delivered treatment. Note that on some newer linacs, MOSAIQ passes information to the treatment unit computer, which is then responsible for ensuring that the desired and actual parameters agree. In addition to the functionality that manages the actual radiation delivery, there is an EMR that provides a clinical cancer database, document and note storage, ordering of medications, assessment of clinical condition, and management of laboratory results, to mention a few.
In our department, the ECL was implemented in January 2009 within the EMR functionality called Clinical Assessments (CA). The CA functionality can be configured as a permanent record in which a user cannot remove an included item from view. It also has the familiar appearance of a spreadsheet, which allows easy checking of pending, completed, and missing items. The CA functionality is also routinely used for the entry of toxicities during patient assessment visits. The entry method can be text or predefined drop-down menu. All entries are time-date stamped and can be configured for mandatory electronic approval. Different levels of security can be assigned to data that are entered, with provisions for multiple signatures if required. An example of the ECL is shown in .
Recently, recommendations have been published that attempt to create a high-safety environment in radiation oncology departments.15
One of the recommendations has included the performance of an accurate and complete QA test before the delivery of radiation therapy. QA should cover all steps in the treatment delivery process; any step vital to accurate radiation dose delivery should be included. This verification process will be similar to the “time-out” for surgery (ie, pause to manually check parameters before beginning, as recommended by the Joint Commission on Cancer), but inherently more complicated. Although surgery has some possibility of retreat even after the start of the operation, the accuracy of the entire radiation process has to be confirmed before pressing the “beam on” button because radiation overdose cannot be corrected.
The process of creating a custom checklist within MOSAIQ is rather straightforward. First, within the Observation Definitions, a tab view is created. This represents the view that the user will see on the screen. The tab view has a uniquely assigned number that facilitates searching for data within the database by using Crystal Reports (SAP AG, Walldorf, Germany), for example. Under the tab view, a number of items can be added. These include higher level folders and subfolders that allow observations to be organized under specific categories. In our case (Figure 1), the major headings include Dosimetry, Physics, Therapy, and Chart Rounds. Subheadings are located under the Therapy folder and include Chart Review, Pre-Treatment, Pre-Port, and First Day of Treatment. Within each of these, data items are added for a particular group. These data items can take the form of a checkbox (checked when completed), numerical data entry, text entry (note), or drop-down selection. The majority of our checklist consists of items that have a checkbox and sections for notes.
The folders and subfolders reflect the clinical flow of data as the radiation treatment (RT) plan is created, verified, and delivered. On completion of the RT plan, and data entry into MOSAIQ, the dosimetrist completes the Dosimetry heading of the ECL. This necessitates review of the accuracy of plan transfer and ensures that all appropriate approvals are obtained from the physician (ie, radiation prescription) before information is passed on to subsequent groups. The RT plan is passed on to a physicist, who verifies the accuracy of the dose calculation, the plan constraints, and consistency of the RT plan with the physician's intent. Completion of this section lets the therapist know that the plan has been reviewed and that he or she can begin the series of pretreatment checks.
The therapist checklists were designed on the basis of previous paper versions of items that are to be checked before treatment, as well as thorough a review of the processes involved in the initiation of treatment. The first step involves reviewing the RT plan with the dosimetrist who created it. As plans have become more complex in recent years, direct communication between the dosimetrist and the therapist helps ensure that the RT plan will be implemented as the physician intended. After the chart review, the therapists will ascertain that the planning documents have all necessary approvals and that the patient is scheduled within MOSAIQ. The Pre-Port checklist is used by the therapist on the day of a trial run of the treatment plan with the patient on the linac table. The therapist uses the ECL to as a reminder to verify all gantry angles and any other devices that are necessary for treatment. At this time, the therapist may also obtain portal images of the patient to ensure that the patient is positioned properly and that the radiation portal shape is correct. For the first day of treatment, the therapist checks that the physician approved the portal images, takes appropriate photos, and provides notes to document the patient set-up to be used during the course of treatment.
Typically, within the first or second week of treatment, patient charts will be reviewed through chart rounds. The Chart Rounds checklist provides the list of items to be reviewed. This portion, however, is part of ongoing QA for peer review and will not be discussed further.