The Joint Commission considers the following a sentinel event:
- Prolonged fluoroscopy with cumulative dose >1500 rads to a single field or,
- Any delivery of radiotherapy to the wrong body region or > 25% above the planned radiotherapy dose.
Most diagnostic fluoroscopy procedures are of short duration, and the skin doses received by patients are well below CRI threshold levels. However, fluoroscopically-guided interventional (FGI) procedures may require the prolonged use of fluoroscopy. Complex FGI procedures can result in PSD levels high enough to cause skin injury. If there is a concern that a sentinel event occurred, follow hospital procedures and contact health physics immediately.
