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The Joint Commission’s Post Exam Incident Identification and Review Requirement

The Joint Commission (TJC) released its updated Diagnostic Imaging Requirements August 10, 2015. While many of these new requirements paired nicely with the new XR-29 equipment standards for dose recording and alerting the technologist when the system “projects” the prescribed scans will exceed the user-configured value (i.e., a pre-exam alert), the section titled Element of Performance for PI.02.01.01 A6. presents an interesting challenge to facilities.  It requires imaging facilities to:

  1. Review and analyze incidents where the radiation dose index from diagnostic CT examinations exceeds expected dose index ranges established for your protocols; and then,
  2. Compare these incidents to external benchmarks.

Essentially, #1 above is a “post-exam” process.  However, the new XR-29 standards do not provide this capability.  The challenge for facilities, therefore, is establishing an efficient process for identifying when the dose exceeded the expected range.  There are several third-party solutions that will help, but many facilities find them prohibitively expensive.  Fortunately, Dose Registry Support Services has developed an easy to use, low-cost solution based on the data each facility submits to the ACR’s Dose Index Registry that identifies every incident retrospectively at intervals the facility determines.

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