A few years ago, I had the pleasure of hearing Andrea Browne, Ph.D speak about the then newly released Joint Commission Dose Incident Identification requirements (PI-02.01.01.A6 standards). Dr. Browne is a Diagnostic Medical Physicist with The Joint Commission and served as one of the primary liaisons between TJC and TJC-accredited organizations as these standards came into effect.
These new standards required facilities to
- develop expected dose ranges for every CT study they performed;
- compare each study’s final total dose to its expected range;
- identify all studies whose total final dose expcced its expected range (referred to as a “dose incident”);
- compare all dose incidents to an external benchmark; and,
- review all dose incidents to see why it exceeded their expected range.
One of Dr. Browne’s favorite sayings was Plan Your Dive and Dive Your Plan. Translated, she meant that facilities should have policies in place governing these and other TJC-related requirements (i.e., Plan your Dive), then they must follow the policies (Dive Your Plan).
In regard to identifying Dose Incidents, TJC didn’t set out exactly how this was to be done. Instead, it left it up to each facility to determine for itself how they would do it. I encourage my clients to have a set of policies specifically related to how they plan to identify dose incidents, and then follow them. These policies should also include timeframes for review and updating certain aspects used in the process, e.g., the expected ranges.
My questions to you are simply:
- Do you have a set of policies in place governing how you identify dose incidents? and,
- Are you following them?