Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging.
The ACR has set a standard for the communication of critical findings on imaging examinations. Despite this standard, for a variety of reasons, it remains possible that appropriate follow-up is not initiated. The authors review the theory and application of root-cause analysis to such a failure of communication within their institution, including the development and implementation of a semiautomated notification system for critical unexpected findings on imaging examinations.
Choksi
Vaishali R
VR
Department of Veterans Affairs, Ann Arbor VA Healthcare System, Ann Arbor, MI 48109-0030, USA. vrchoksi@med.umich.edu
Marn
Charles
C
Piotrowski
Marcia M
MM
Bell
Yvonne
Y
Carlos
Ruth
R
D016638:Critical Illness; D003952:Diagnostic Imaging / Q000592:standards*; D018563:Disease Notification / Q000592:standards*; D049228:Healthcare Common Procedure Coding System; D006801:Humans; D033162:Incidental Findings; D008175:Lung Neoplasms / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D011787:Quality of Health Care; D011859:Radiography; D011872:Radiology Department, Hospital; D018570:Risk Assessment; D017751:Safety Management; D014481:United States