[Intl_DxMedPhys] TJC and NQF update to Sentinel Events List

[Dave Jordan]

The document says these SREs will be transitioned to sentinel events because they meet the definition: "“A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm).”

I don't agree that that definition applies to these two SREs as written, although I do agree that these are preventable. An MRI thermal injury could meet the definition above but will not always result in severe or permanent harm. Ferromagnetic objects getting into Zone IV "regardless of the outcome" also does not necessarily reach the patient or result in severe or permanent harm or death.

I don't want to take away from the seriousness of these two event types because they have the potential to result in sentinel events. Maybe that's a distinction without a difference? And maybe these are, and should be, so rare and so serious that they should get the sentinel event treatment even if they are a "near miss"?

I guess practically speaking, these things should be treated like sentinel events whether they technically are, or are not; taking the definition at face value, though, it's a reach. In any case, if MRI burns or Zone IV breaches are happening in a facility so frequently that handling each as a SE would be overwhelming, then one way or another, that's something that really needs to get fixed.

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On Jan 28, 2026 at 2:56 PM -0500, Pate, William J. <wjpate at utmb.edu>, wrote:
> From my reading of the document, effective 2027, all of these SREs will be considered Sentinel Events by TJC.
>
> Sincerely,
>
> Will
>
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> From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu> On Behalf Of Dave Jordan via Intl_dxmedphys_wd_osu_list
> Sent: Wednesday, January 28, 2026 1:47 PM
> To: Andreea D <adohatcu at gmail.com>; Mary Ellen Jafari <MaryEllen.Jafari at kp.org>
> Cc: intl_dxmedphys_wd_osu_list at lists.osu.edu
> Subject: Re: [Intl_DxMedPhys] TJC and NQF update to Sentinel Events List
>
>
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> I think it's important to make a distinction between a sentinel event and a serious reportable event. I do think these preventable and serious safety issues in MRI warrant treatment as SRE's. I do not think there is justification to treat them
> I think it's important to make a distinction between a sentinel event and a serious reportable event. I do think these preventable and serious safety issues in MRI warrant treatment as SRE's. I do not think there is justification to treat them as sentinel events (events that result in patient death, permanent harm, or temporary harm severe enough to require intervention to sustain life). It is true that these kinds of incidents could lead to sentinel events, which is why they make sense to give some specific attention and handling as SREs.
>
>
> ---
> On Jan 28, 2026 at 2:09 PM -0500, Andreea D via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu>, wrote:
>
> > To me "SRE 5: Introduction of an unapproved, unscreened, or inappropriately approved device, implant, or object into an MRI Zone IV. " is not necessarily related to patient not to an injury. Hence the novelty and extra work. Am i missing
> > To me "SRE 5: Introduction of an unapproved, unscreened, or inappropriately approved device, implant, or object into an MRI Zone IV." is not necessarily related to patient not to an injury.
> > Hence the novelty and extra work. Am i missing something?
> >
> > Thank you,
> > Andreea
> >
> > On Wed, Jan 28, 2026, 12:37 PM Mary Ellen Jafari via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:
> > > quote_type
> > > I don’t see that there is really much of an impact because as William says, the TJC standards already require identifying thermal injury and patient injury and doing rca, investigation, and corrective action. And reporting is still voluntary.
> > > I don’t see that there is really much of an impact because as William says, the TJC standards already require identifying thermal injury and patient injury and doing rca, investigation, and corrective action.  And reporting is still voluntary.  If mandatory reporting was required, that would be a major change.
> > >
> > > Mary Ellen Jafari, MS, DABR (D,N), MRSE, MRSO, FACR, FAAPM, CIIP
> > > Chief Physicist and Regional Radiation Safety Officer
> > >
> > > Kaiser Permanente
> > > Southern California Permanente Medical Group Medical Imaging Technology and Informatics
> > > 199 S. Los Robles Ave., Pasadena CA 91101
> > > 626-430-1231 (office mobile)
> > > Maryellen.Jafari at kp.org
> > >
> > > From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu> On Behalf Of William Sensakovic via Intl_dxmedphys_wd_osu_list
> > > Sent: Wednesday, January 28, 2026 8:43 AM
> > > To: intl_dxmedphys_wd_osu_list at lists.osu.edu
> > > Subject: Re: [Intl_DxMedPhys] TJC and NQF update to Sentinel Events List
> > >
> > > 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
> > > Caution: This email came from outside Kaiser Permanente. Do not open attachments or click on links if you do not recognize the sender.
> > > 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:
> > > > quote_type
> > > > 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)
> > > >
> > > > Travis
> > > >
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