Radiology Imaging

Citation

TJC MM.13.01.01

The hospital safely stores medications.

The hospital must safely store medications, including controlled substances and radiopharmaceuticals, to prevent diversion.

Citation

TJC MM.15.01.01

The hospital safely prepares medications.

The standard addresses pharmacist supervision, sterile compounding policies, staff competency, compounding environments, storage, labeling, quality assurance, and radiopharmaceutical preparation oversight.

Citation

TJC MS.16.01.01

The organized medical staff oversees the quality of patient care, treatment, and services pro...

Addresses organized medical staff responsibility for care quality, privileges, patient safety, histories and physicals, emergency care policies, and selected radiology and nuclear medicine staff qualifications.

Citation

TJC MS.17.01.03

The hospital collects information regarding each physician's or other licensed practitioner’s...

The hospital must collect and verify credentialing information for practitioners seeking privileges and, for deemed status hospitals, ensure qualified radiologist supervision of ionizing radiology services.

Citation

TJC NPG.01.02.01

The hospital reports critical results of tests and diagnostic procedures on a timely basis.

The hospital maintains written procedures for defining, reporting, timing, and evaluating critical results of tests and diagnostic procedures.

Citation

TJC NPG.13.01.01

The hospital defines and verifies qualifications and education requirements for imaging servi...

Requires the hospital to define and verify qualifications, certifications, and ongoing education for CT technologists, medical physicists, and MRI technologists.

Citation

TJC NPG.13.02.01

The hospital’s imaging services have a designated leader and follow current safe imaging prac...

Requires a designated radiation safety officer, adherence to recognized radiology safety standards, and current CT imaging protocols reviewed with clinical and physics input.

Citation

TJC NPG.13.03.01

The hospital manages imaging safety risks.

The hospital manages MRI, CT, PET, nuclear medicine, and fluoroscopy safety risks through access controls, signage, dosimetry monitoring, and annual medical physicist performance evaluations.

Citation

TJC NPG.13.04.01

The hospital monitors quality improvement projects related to imaging safety.

The hospital collects, reviews, and analyzes data on MRI thermal injuries, ferromagnetic incidents, and CT radiation dose index exceedances as part of its quality improvement program.

Citation

TJC PC.12.01.01

The hospital provides care, treatment, and services as ordered or prescribed and in accordanc...

Requires the hospital to provide care, treatment, and services as ordered by licensed practitioners in accordance with law, regulation, and professional standards, with specific conditions for outpatient orders, blood transfusions, IV medications, and rehabilitation services.

Citation

TJC PE.02.01.01

The hospital manages risks related to hazardous materials and waste.

Requires the hospital to inventory, label, handle, store, and dispose of hazardous materials and waste, including radioactive, chemical, gas, vapor, and regulated medical waste, while protecting patients and staff.

Citation

TJC PE.04.01.01

The hospital addresses building safety and facility management.

Requires the hospital to comply with the Health Care Facilities Code and maintain essential equipment, ventilation, lighting, temperature control, and supplies in pharmaceutical, patient care, food preparation, and nuclear medicine areas.

Citation

TJC PE.05.01.01

The hospital manages imaging safety risks.

Requires the hospital to manage imaging safety risks by ensuring annual performance evaluations of nuclear medicine, PET, CT, MRI, and fluoroscopic imaging equipment by qualified medical physicists, with documented results and corrective recommendations.