On August 24, 2011, the Joint Commission issued a Sentinel Event Alert (the “Alert”) regarding the risks associated with diagnostic imaging.  The Alert notes that although there is disagreement among experts about the risk of cancer from diagnostic imaging, there is agreement that measures should be taken to eliminate unnecessary exposure to radiation.  Providers are urged to carefully consider the medical necessity of a given level of radiation exposure.  The Alert notes that as a result of the risks associated with diagnostic imaging, the Centers for Medicare and Medicaid Services (CMS) will require the accreditation of freestanding imaging facilities providing advanced imaging services beginning January 1, 2012.  The Joint Commission also cites to legislation enacted by the state of California that requires documentation of the radiation dose received by the patient for each CT examination. 

In May 2011, the American College of Radiology (ACR) launched a National Radiology Data Registry (NRDR).  The NRDR is a warehouse of ACR registry databases that compares radiology facilities regionally and nationwide according to facility type.  The NRDR allows facilities to compare their results to regional and national benchmarks for quality improvement purposes.

The Joint Commission’s Alert states that healthcare organizations can reduce risks due to avoidable diagnostic radiation by, among other things, raising awareness among staff and patients of the potential risks, providing the right test and dose through effective processes, safe technology and promoting a culture of safety. The specific actions suggested by the Joint Commission include the following:

  • Use other imaging techniques, such as ultrasound or MRI, whenever these tests will produce the required diagnostic information at a similar quality level;
  • Adhere to ALARA guidelines as required by the Nuclear Regulatory Commission. The ALARA acronym stands for “as low as reasonably achievable”—making sure doses are as low as possible while achieving the purposes of the study;
  • Radiologists should confirm that the proper dosing protocol is in place for the patient being treated;
  • Ensure all physicians and technologists who prescribe diagnostic radiation or use diagnostic radiation equipment receive dosing education and are trained on the specific model of equipment being used;
  • Have a qualified medical physicist test all diagnostic imaging equipment initially and at least annually or every two years thereafter to assure proper installation and calibration, and review scanning protocols and doses; and
  • Use the following Joint Commission standards to support the use of safe and effective diagnostic radiation: LD.03.01.01, LD.03.04.01, LD.03.05.01, LD.03.06.01.

According to the Alert, the Joint Commission endorses the creation of a national registry to track radiation doses, encourages manufacturers to incorporate dosage safeguards into diagnostic imaging equipment and supports stricter regulations designed to eliminate avoidable imaging and monitor the appropriateness of self-referred imaging studies.

The Joint Commission Alert is available by clicking here.