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The Joint Commission Standard PC.01.02.15: Medical Imaging Processes, Elements of Performance, and Malpractice Implication

  • Writer: EvaluCare
    EvaluCare
  • 7 days ago
  • 9 min read

Medical imaging is one of the great advances in medical care. The systems around it are fallible and The Joint Commission Provisions of Care can serve as a baseline of expectations to ensure care is delivered safety and effectively.
Medical imaging is one of the great advances in medical care. The systems around it are fallible and The Joint Commission Provisions of Care can serve as a baseline of expectations to ensure care is delivered safety and effectively.

In today’s healthcare environment, prompt and accurate diagnostic imaging is often pivotal to timely diagnosis and treatment. When imaging processes break down, whether through delayed scans, missing orders, or failure to act on results, the risk of missed or delayed diagnoses, patient harm, and malpractice claims rises sharply. The Joint Commission recognizes this in Standard PC.01.02.15, which specifically addresses the hospital’s responsibility to ensure that diagnostic imaging services (including ordering, performing, interpreting, and following up) are executed in a safe, timely, and coordinated manner.


Below, we’ll explore each of the standard’s Elements of Performance (EPs), explain their rationale, and provide medical malpractice–style examples illustrating what can happen when an organization fails to meet these requirements. Note that standards are updated every year and this is not meant to be an exact match to the standards but provide patients and families with information on the care that is required to be taken during the course of care.


If you, or someone you love, or represent, have been harmed related to this standard of care, please reach out to EvaluCare to discuss an independent, trusted, thorough review of medical care. Find out more at: EvaluCare.net


Overview of Standard PC.01.02.15

“The hospital orders, obtains, and reports diagnostic imaging results in a timely manner and takes action based on the results.”

In essence, this standard requires hospitals to have a written, system‑wide process that ensures:

  1. Appropriate ordering of diagnostic imaging (e.g., X‑rays, CT scans, MRI, ultrasound).

  2. Timely performance of those studies after the order is placed.

  3. Prompt interpretation by qualified personnel.

  4. Immediate communication of critical or unexpected findings.

  5. Documentation that the ordering practitioner has seen, acknowledged, and acted on the report.


Without robust policies and reliable workflows to enforce these steps, imaging results can slip through the cracks—leading to misdiagnoses, delayed treatment, and potential harm.


Elements of Performance (EPs) for PC.01.02.15

Joint Commission Standard PC.01.02.15 currently comprises five Elements of Performance. Below, each EP is described along with a practical explanation and a hypothetical malpractice‐style example illustrating what can go wrong when it’s neglected.


EP 1. Written Process for Ordering and Tracking Imaging

Requirement:The hospital must have a written, organized process that defines:

  • Who can order imaging studies (e.g., physicians, advanced practice providers).

  • How orders are entered into the electronic health record (EHR) or paper chart.

  • Mechanisms for tracking an order through to performance and result reporting.


Rationale:Clearly defined roles and steps reduce confusion. If it’s unclear how orders enter the system or who is responsible for chasing down incomplete orders, imaging may never even get scheduled.


Malpractice Example:A 62‑year‑old man with sudden onset back pain is seen in a community hospital’s ED. A junior resident writes “spine X‑ray” on a paper form but fails to notify radiology staff. Because the hospital has no standardized policy requiring orders to be rechecked by a charge nurse or radiology scheduler, the X‑ray is never performed. Two days later, the patient returns with paraplegia; later, MRI reveals a malignant spinal cord compression that went undiagnosed.


  • Why It’s Malpractice: The hospital breached its duty of care by failing to implement a reliable order entry and tracking system (EP 1). The missing X‑ray led directly to delayed diagnosis of spinal cord compression. A timely X‑ray would likely have prompted further imaging (MRI) and faster oncologic referral, potentially preventing paralysis.


EP 2. Defined Timeframes for Completing Ordered Imaging Studies

Requirement:The hospital must specify, in writing, the acceptable timeframes for completing each type of imaging order (e.g., “CT scans for suspected stroke within 25 minutes of arrival,” “stat abdominal ultrasound within 60 minutes,” or “non‑urgent chest X‑ray within 4 hours”). These benchmarks should be tailored to clinical urgency, imaging modality, and patient location (ED vs. inpatient ward vs. ICU).


Rationale:Without defined timeframes, imaging can be delayed indefinitely—especially during high‐volume periods. Timeliness is crucial for time‐sensitive conditions (e.g., stroke, acute abdominal pain, pulmonary embolism).


Malpractice Example: A 45‑year‑old woman arrives in the ED complaining of acute chest pain and shortness of breath. The attending physician orders a stat CT pulmonary angiogram to rule out pulmonary embolism. The hospital’s policy provides no specific timeframe for “stat” CTs during peak hours. The CT is not performed until three hours later due to an overbooked radiology schedule. In the interim, the patient develops hypotension and dies of a massive pulmonary embolism.


  • Why It’s Malpractice:  By failing to define (and enforce) a timeframe for “stat” CT angiograms, the hospital did not meet the duty of care under EP 2. A CT within 60 minutes could have detected the embolism and triggered anticoagulation before deterioration. The absence of a clear protocol directly contributed to a preventable death.


EP 3. Qualified Practitioners for Interpretation

Requirement: The hospital must ensure that all diagnostic imaging studies are interpreted by practitioners with the appropriate credentials (e.g., Board‑certified radiologists or credentialed ultrasound technologists with physician overreads). If tele‐radiology is used after hours, contracted radiologists must meet the same credentialing standards as on‑site staff.


Rationale: Misinterpretation or lack of expert review can lead to false negatives or positives. Having unqualified staff read complex studies risks misdiagnosis.


Malpractice Example: An elderly patient with abdominal pain receives an ultrasound at 2 a.m. The hospital’s policy allows an on‑call radiology resident, who is not yet board certified, to finalize preliminary reads without radiologist overreads for “after-hours” ultrasounds. The resident fails to recognize signs of an early aortic aneurysm (measuring 5.5 cm), reads the study as “normal,” and releases the patient home. Six hours later, the patient returns in extremis with a ruptured aneurysm and subsequently dies.


  • Why It’s Malpractice: EP 3 mandates that interpretations be performed, or at least validated, by credentialed, experienced practitioners. Bypassing radiologist overreads after hours led to a missed aneurysm. This organizational lapse in credentialing and interpretation planning extinguished the duty of care, culminating in preventable fatality.


EP 4. Prompt Communication of Critical Results

Requirement: The hospital must define what constitutes a “critical” or “unexpected” finding and ensure that those results are communicated immediately (for life‑ or limb‑threatening conditions) to the ordering or attending practitioner. The communication method (phone, secure messaging, automatic EHR alerts) and documentation of the communication must be spelled out in policy.


Rationale: Discovering a critical finding (e.g., subdural hematoma, high‑grade obstruction, acute fracture) has no value if it’s not relayed immediately to the clinician who can act on it. Delays in communication can be just as dangerous as delays in imaging.


Malpractice Example: A hospitalized patient with acute kidney injury undergoes a contrast‑enhanced CT to evaluate for obstructive uropathy. The radiologist identifies a large obstructing ureteral stone with hydronephrosis. However, because the hospital’s policy classifies only “brain bleeds” and “aortic dissections” as “critical” and fails to list obstructing stones in its criteria, the radiologist files the report without immediate notification. Twenty‑four hours later, the urology team sees the report and schedules a stent placement two days out. During the interim, the patient develops urosepsis and multi‑organ failure.

  • Why It’s Malpractice: By not including obstructing stones, and associated severe hydronephrosis, as a critical finding in its policy, the hospital violated EP 4. The delay in communicating a serious blockage breached duty of care and directly led to sepsis and preventable morbidity.


EP 5. Complete Documentation of Result Review and Follow‑Up

Requirement: Once imaging results are finalized, the ordering (or appropriate covering) practitioner must review them, interpret the findings, and document any follow‑up actions (e.g., “CT chest shows 3 cm lung nodule, will arrange PET scan” or “negative head CT—no acute bleed, will monitor clinically”). The hospital must also track that these follow‑ups occurred (e.g., biopsies scheduled, interventional radiology consults placed).


A closed‑loop system is required:

  1. Radiology → Ordering Practitioner: final report and notification.

  2. Ordering Practitioner → Documentation: acknowledgment of receipt and plan.

  3. Care Team → Execution: ensure orders (e.g., additional tests, referrals) are scheduled and completed.


Rationale: Even if a study is performed, read, and communicated, the process isn’t complete until someone acts on it. Failure here can result in “orphaned” abnormal findings that patients never address.


Malpractice Example: A 55‑year‑old woman with chronic cough receives a chest X‑ray. Radiology’s final report, documented in the EHR, notes a suspicious 2 cm right upper lobe nodule. However, the ordering physician (a hospitalist covering a busy inpatient service) neither documents acknowledgment of the report nor places orders for follow‑up CT or pulmonology referral. Because there is no tracking system to flag unreviewed or unacted upon abnormalities, nobody revisits the finding. Six months later, she presents with metastatic lung cancer.

  • Why It’s Malpractice: Neglecting to review and follow up on an abnormal chest X‑ray violates EP 5. The hospital didn’t maintain a closed‑loop process to ensure critical imaging findings prompted timely intervention. This organizational failure breached the duty of care, with delayed cancer diagnosis leading to advanced disease and potentially reduced survival.


Why Failure to Comply Often Equals Malpractice

Under U.S. tort law, medical malpractice typically requires proof of four elements:

  1. Duty: The healthcare organization (and its practitioners) owed the patient a standard of care.

  2. Breach: The organization failed to meet that standard.

  3. Causation: The breach directly led to injury or harm.

  4. Damages: The patient suffered quantifiable harm (e.g., disability, additional treatment, death).


When a hospital violates PC.01.02.15, by not having clear policies, failing to meet timeframes, allowing unqualified interpretation, omitting critical result communication, or neglecting follow‑up, the duty is breached. If that breach leads to a missed or delayed diagnosis (for example, a ruptured abdominal aortic aneurysm) and the patient is harmed, the hospital can be held liable for malpractice. The common thread in each of the examples above is that a system failure (not a single physician’s error) caused harm—demonstrating organizational negligence.


Best Practices for Compliance

To reduce risk and promote patient safety, EvaluCare in its medical care review reports provided to patients, families and attorneys will offer recommendations for compliance to standards that can be provided to hospitals to:

  1. Develop or Update Written Imaging Policies (EP 1–2):

    • Clearly specify who may order each modality (e.g., CT, ultrasound).

    • Define “stat,” “expedited,” and “routine” timeframes for completion.

    • Institute an electronic tracking board that shows orders awaiting performance.

  2. Credential and Audit Interpreters (EP 3):

    • Maintain up‑to‑date privileges for all radiologists, sonographers, and credentialed physicians.

    • If outsourcing to tele‑radiology, verify that contracted radiologists meet the same standards.

    • Periodically audit a sample of interpretations for quality metrics (accuracy, turnaround time).

  3. Implement a Critical Result Notification Pathway (EP 4):

    • Define “critical” and “unexpected” results in writing. Examples: intracranial hemorrhage, tension pneumothorax, large pulmonary embolism, obstructing stone with sepsis risk.

    • Require radiologists to phone or secure‑message the ordering/attending practitioner within a specific timeframe (e.g., within 30 minutes of finalizing the report).

    • Log all critical result communications in a secure tracking system.

  4. Close the Loop on Abnormal Findings (EP 5):

    • Generate automatic alerts for abnormal results that remain unacknowledged after a set period (e.g., 24 hours).

    • Have care coordinators (e.g., nurse navigators) reach out if a required follow‑up imaging or consult hasn’t been scheduled.

    • Document each step in the EHR: receipt by ordering practitioner → care plan adjustment → scheduling of additional tests or referrals.

    In this way, EvaluCare does its part to make care safer.


Conclusion

PC.01.02.15 is not merely an administrative checkbox; it’s a fundamental patient‑safety requirement that governs everything from ordering a chest X‑ray to acting on a life‑threatening CT finding. By adhering to each Element of Performance, defining who may order studies, establishing timeframes, ensuring qualified interpretation, communicating critical results, and closing the loop on follow‑up, hospitals can significantly reduce the risk of diagnostic delays, potential malpractice, and preventable patient harm.


When organizations fail to develop or enforce these processes, they breach their duty of care. The examples above illustrate real‑world consequences: missed spinal lesions causing paralysis, undiagnosed pulmonary emboli leading to death, overlooked aneurysms, and hidden malignancies. In each scenario, the root cause is a system failure to comply with PC.01.02.15, not just human error, making it distinctly organizational malpractice.


For hospital leaders, risk managers, and front‑line clinicians, the takeaway is clear: robust, well‑documented imaging workflows aren’t optional—they’re essential. By proactively reviewing current policies, educating staff, and monitoring compliance with PC.01.02.15, your organization can better safeguard patients, avoid legal exposure, and fulfill its core mission: uninterrupted, timely, high‑quality patient care.


If you suspect that you, a loved one, or someone you know, or represent, have been a victim of a medical error or medical malpractice, please reach out to EvaluCare for a independent medical care review to find answers. EvaluCare.net





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Helpful Links & Resources

To learn more about PC.01.02.15, diagnostic imaging best practices, and risk management, refer to the following authoritative resources:

  1. Joint Commission – Comprehensive Accreditation Manual for Hospitals (CAMH)

    • Provision of Care, Treatment, and Services Chapter (PC), Standard PC.01.02.15

    • Access (via JC Connect; subscription required):https://manual.jointcommission.org/releases/TJC2025A/PC/

    • If your organization is accredited, log in to Joint Commission Connect and navigate to “Manuals & Tools → CAMH → Hospitals → PC.”

  2. R3 Reports (Requirement, Rationale, Reference) – Joint Commission

  3. Joint Commission’s Hospital Survey Activity Guide (SAG)

  4. American College of Radiology (ACR) Appropriateness Criteria

  5. Joint Commission Sentinel Event Data Summary (Up to 2024)

  6. Agency for Healthcare Research and Quality (AHRQ) – Diagnostic Safety

  7. Radiology Business Management Association (RBMA) – Best Practices



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