Reported number of fluoro-radiation incidents remains low

Sentinel events reported to the Joint Commission involving prolonged fluoroscopy or radiation to the wrong body region appear to be low and are holding steady, based on a midyear report for 2014.

The Joint Commission has tracked the incidence of sentinel events since 1995. It defines a sentinel event as the occurrence or risk of unanticipated death or serious physical or psychological injury that needs to be investigated immediately. The commission tracks reviewable events, with the more common being related to falls, treatment on the wrong patient/site/procedure, unintended retention of foreign objects and unanticipated events such as choking.

In 2005, it added prolonged fluoroscopy with a cumulative dose of more than 1,500 rads to a single field or radiotherapy to the wrong body region exceeding 25 percent of the planned dose. Between 2006 and 2011, reporting of these events climbed from three to eight. The number dropped to three in 2012 and four in 2013.

In the first two quarters of 2014, there were a total of 394 reports of sentinel events, two involving prolonged fluoroscopy or radiotherapy to the wrong body region. By contrast, the number of midyear fall-related events and retention-related events were 44 and 57, respectively.

Reports of sentinel events are voluntary, though, and the Joint Commission cautions that they represent a sliver of actual events.

Candace Stuart, Contributor

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