In August of 2011, The Joint Commission (TJC) issued Sentinel Event Alert #47, titled Radiation Risks of Diagnostic Imaging. Last month an update to this alert was issued to specifically include fluoroscopy and to more clearly define a patient safety program. The core of this alert remains the same; however, this revision makes it clear TJC wants their accredited sites to include fluoro safety when considering radiation risks associated with diagnostic imaging. The alert is now titled: Radiation Risks of Diagnostic Imaging and Fluoroscopy. While the alert is only recommendations and not a standard, we at MPC view this information as a cheat sheet to how the TJC will interpret the standard. The revised alert includes a recommendation that the patient safety program should include education for practitioners and staff, which covers ALARA concepts and typical doses and dose ranges. Furthermore, patients, staff, and leadership should be aware of “potential dangers from excessive radiation exposures”. Another change is that the alert now includes a recommendation to follow Image Wisely® and Step Lightly® guidelines. Clarified wording provides insight on education for individuals who “prescribe, supervise, or operate” radiation producing equipment. This includes annual education and review on exposure information and the operation of the specific make and model of the equipment being used all of which must include competency testing. Please reach out to your MPC physicist for guidance on how we can help you achieve the goals the JC is striving for. Tim-Tim!
The updated Sentinel Event Alert updated report can be found here: SEA_47_Radiation_REVISED2_Feb_20181.
The referenced Joint Commission standard can be found here: Prepub_HAP_Fluoroscopy_Revisions_20180613