title: Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging.
abstract: 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.
authors.affiliation: Department of Veterans Affairs, Ann Arbor VA Healthcare System, Ann Arbor, MI 48109-0030, USA. vrchoksi@med.umich.edu
authors.forename: Vaishali R
authors.initials: VR
authors.lastname: Choksi
authors.forename: Charles
authors.initials: C
authors.lastname: Marn
authors.forename: Marcia M
authors.initials: MM
authors.lastname: Piotrowski
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Bell
authors.forename: Ruth
authors.initials: R
authors.lastname: Carlos
mesh_terms: 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