[Intl_DxMedPhys] TJC and NQF update to Sentinel Events List

[Christina Brunnquell]

I suppose I am thinking less about the patient injury-related ones and more
about SRE 5: Introduction of an unapproved, unscreened, or inappropriately
approved device, implant, or object into an MRI Zone IV.

Looking back in my records, in our large health system these have happened
a few times a year in the last few years, usually due to patients not
disclosing things like hair extensions with metallic components or "healing
magnets" tucked into their undergarments. I suppose these would result in
an RCA process that is relatively simple and yes there is always sharing of
information to all our sites and discussion of whether there are changes
that should be made to the screening process or other policies, etc.

Maybe I'm overblowing the concept of a sentinel event in my mind; I have
not been involved in managing any in the past.

Christina


On Wed, Jan 28, 2026 at 10:43 AM William Sensakovic via
Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> Now that there is a charge associated with safety it makes sense they
> would also want to ensure work is actually happening. Yes, I know this is
> not directly tied to the charge, but the timing is not surprising. Also,
> every place should already
> Now that there is a charge associated with safety it makes sense they
> would also want to ensure work is actually happening. Yes, I know this is
> not directly tied to the charge, but the timing is not surprising. Also,
> every place should already be doing rca and the other steps when there is
> patient injury regardless of cause so my guess is that they assume this is
> essentially a net 0 increase in work.
>
> William F. Sensakovic, PhD, MRSC(MRSE), FAAPM
> Chair and Assoc. Prof., Mayo Clinic (Arizona)
> Founder, Telerad Physics Teaching, LLC
> ------------------------------
> *From:* Intl_dxmedphys_wd_osu_list
> <intl_dxmedphys_wd_osu_list-bounces+wfsensak=outlook.com at lists.osu.edu>
> on behalf of Christina Brunnquell via Intl_dxmedphys_wd_osu_list <
> intl_dxmedphys_wd_osu_list at lists.osu.edu>
> *Sent:* Wednesday, January 28, 2026 9:06:38 AM
> *To:* Travis Greene <TGreene at radser.com>
> *Cc:* intl_dxmedphys_wd_osu_list at lists.osu.edu <
> intl_dxmedphys_wd_osu_list at lists.osu.edu>
> *Subject:* Re: [Intl_DxMedPhys] TJC and NQF update to Sentinel Events List
>
> Wow, this is a really big change. Thanks for the heads up, Travis. Of
> course we work hard to minimize such events but in comparison to my mental
> benchmark of sentinel events (15 Gy PSD, which yes I know is no longer a
> SE, but it's still
> Wow, this is a really big change. Thanks for the heads up, Travis. Of
> course we work hard to minimize such events but in comparison to my mental
> benchmark of sentinel events (15 Gy PSD, which yes I know is no longer a
> SE, but it's still my mental benchmark), these events are substantially
> more common. I'm interested in a gut check on other MR safety folks'
> thoughts/impressions, feel free to respond directly.
> Christina
>
> On Tue, Jan 27, 2026 at 9:17 AM Travis Greene via
> Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu>
> wrote:
>
> Colleagues, I came across this information in a social media post
> regarding MRI safety. The Joint Commission and National Quality Forum have
> released their January 2026 report, "Aligning Patient Safety Event
> Reporting: 2025 Updates to Sentinel
>
> Colleagues,
>
>
>
> I came across this information in a social media post regarding MRI safety.
>
>
>
> The Joint Commission and National Quality Forum have released their
> January 2026 report, "Aligning Patient Safety Event Reporting: 2025 Updates
> to Sentinel Events and Serious Reportable Events".  The 2025 NQF SRE list
> now has 28 events in four categories, with 23 updated/modified from the
> 2011 list and several new additions.
>
>
>
> TJC will adopt the updated SRE list into its SE list effective January 1,
> 2027, giving accredited organizations time to prepare. Reporting remains
> voluntary, but TJC expects accredited organizations to identify these
> events, perform root cause analysis, and implement improvements to prevent
> recurrence.  Of interest to us, SRE 5 and SRE 6 relate to MRI Safety.
>
>
>
>    - *SRE 5:* Introduction of an unapproved, unscreened, or
>    inappropriately approved device, implant, or object into an MRI Zone IV.
>    - *SRE 6: *Patient harm associated with an MRI-related thermal injury.
>
>
>
> For complete details, please see the attached report.  (2025 SE & SRE
> Report
> <https://urldefense.com/v3/__https://digitalassets.jointcommission.org/api/public/content/b4e8988066e74717ae9801edb2bfb9de?v=e0ff96a2__;!!KGKeukY!yHalqw2LntpjV0KyVuGkrIx9M19ApDNRf5WlfG9-YA39tx-gQrdMBS6DPaj_N0q48x8QVbdsH77WPg9EGUrrrebIsyENjjPVL27onA$>
> )
>
>
>
> Travis
>
>
>
>
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