TJC Revisions to Fluoroscopy Imaging Standards, Effective July 1, 2018

PUBLISHED: Feb 28, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals, Medical Office

The Joint Commission (TJC) has issued changes for two (2) standards related to fluoroscopy services to clarify expectations and increase awareness about radiation exposure risks when using this type of imaging.

The changes are applicable to ambulatory care, office-based practices, hospitals and critical access hospitals and is effective July 1, 2018.

TJC Environment of Care standard EC.02.02.01 requires the organization to manage risks associated with hazardous materials and waste. TJC has made revisions to Elements of Performance within this standard to clarify:

  • There must be proper shielding of the patient during fluoroscopic procedures as part of the larger approach to minimizing risk associated with using hazardous energy sources.
  • Organizations providing fluoroscopy services must review, at least quarterly, the results of dosimetry monitoring. The review should be conducted by the radiation safety officer, diagnostic medical physicist, or health physicist and assess whether staff radiation exposure levels are “as low as reasonably achievable” (ALARA) and below regulatory limits.

Included with today’s notice are example policies related to these new requirements. Follow the link below to review TJC’s prepublication standards.

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