Within the last year, the Joint Commission has received reports of two separate incidents at accredited hospitals where patients--a total of 14--may have been exposed to Creutzfeldt-Jakob Disease through instruments used during brain surgeries. Although CJD is rare--only one in one million people worldwide have been diagnosed with CJD--and iatrogenic transmission of CJD by exposure to central nervous system tissue or spinal fluid of a diseased person is even rarer, these new incidents signal the need for renewed awareness of preventive measures in health care organizations in regards to infection control (Comprehensive Accreditation Manual for Hospitals, IC.1-IC.6.2). This is particularly important since regular sterilization techniques are not yet proven to be effective against the CJD organism.