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TJC Dose Monitoring Requirements: XR-29 Dose Notifications Don’t Meet Them

When the facility I was working with was exploring using their scanners’ XR-29 Notifications to meet PI 02.01.01.A6 Dose Incident Identification requirements we reviewed the technical elements underpinning XR-29’s Dose Check feature.  After reading them we grew very concerned that XR-29’s dose notifications would not meet TJC’s requirement.  The facility submitted a question to TJC asking about this specific issue.  We were correct to be concerned; TJC’s response indicated XR-29 Dose Notifications don’t meet the requirements.  Here is a copy of their response:


TJC requires facilities establish the expected total dose ranges (CTDIvol, DLP, or SSDE) for each protocol and then test the actual total dose imparted after the exam has been completed to the protocol’s expected total.  The total is across all irradiation events;  this includes the sum of the pre-monitoring, bolus tracking, and then actual scan series dose values.  In the image below that equates to the Total DLP at the top of the image or the sum of the doses listed in the CTDIvol values column. 

Dose Page

There are several ways of complying with TJC’s dose incident identification requirements, some expensive, some free or nearly so. 

You may get lucky and have TJC auditors that don’t yet understand the technical aspects of dose monitoring.  However, this facility did not want to take that chance.  Dose Registry Support Services can provide facilities with a very low-cost, fully TJC compliant program using your DIR data and avoid the expense of purchasing and then operating a third-party software solution. 


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