Meeting The Joint Commission’s Dose Incident Identification Requirement Using the ACR’s Dose Index Registry

Here is the Abstract and link to an article I co-authored which was recently published in the JACR online edition, and which will be published in the JACR August print edition.

The article describes how we used our ACR Dose Index Registry data to meet The Joint Commission’s requirement to establish expected dose ranges for every CT protocol and then identify any study that exceeds its expected range for review and analysis.

Link to JACR Article




The purpose of this investigation was to evaluate the potential of using the ACR’s Dose Index Registry® to meet The Joint Commission’s requirements to identify incidents in which the radiation dose index from diagnostic CT examinations exceeded the protocol’s expected dose index range.


In total, 10,970 records in the Dose Index Registry were statistically analyzed to establish both an upper and lower expected dose index for each protocol. All 2015 studies to date were then retrospectively reviewed to identify examinations whose total examination dose index exceeded the protocol’s defined upper threshold. Each dose incident was then logged and reviewed per the new Joint Commission requirements.


Facilities may leverage their participation in the ACR’s Dose Index Registry to fully meet The Joint Commission’s dose incident identification review and external benchmarking requirements.

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