[Intl_DxMedPhys] TJC and NQF update to Sentinel Events List

[Alisa Walz-Flannigan]

I’m familiar with TJC surveyors asking for ferromagnetic intrusion logs for some years now.

Logging  has been tricky. Having techs enter an incident report because someone passed a threshold before remembering a bobby pin feels like a hard sell. I tried alternative, simplified online logging (outside of incident reporting system) without much success. curious what others have done and with what success (to their knowledge).
-Alisa


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

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.


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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<mailto: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<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu>> wrote:
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<https://urldefense.com/v3/__https:/www.google.com/maps/search/199*S.*Los*Robles*Ave.,*Pasadena*CA*91101?entry=gmail&source=g__;KysrKysrKw!!KGKeukY!yw875nSvB38npAzN5b8jVOQkdapKOMZHBbWpv8cip-uwTVITBDJzIGWqtIjHDVgAL30T1-aamcx-xxydoEYc61Sjx-SuXwvv2xcgYVk$>
626-430-1231 (office mobile)
Maryellen.Jafari at kp.org<mailto:Maryellen.Jafari at kp.org>

From: Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces at lists.osu.edu<mailto: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<mailto: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

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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<mailto: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<mailto: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<mailto:TGreene at radser.com>>
Cc: intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto:intl_dxmedphys_wd_osu_list at lists.osu.edu> <intl_dxmedphys_wd_osu_list at lists.osu.edu<mailto: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<mailto: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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