title: Critical Findings: Attempts at Reducing Notification Errors.
abstract: OBJECTIVE
  Ineffective communication of critical findings (CFs) is a patient safety issue. The aim of this study was to assess whether a feedback program for faculty members failing to correctly report CFs would lead to improved compliance.
  
  
  METHODS
  Fifty randomly selected reports were reviewed by the chief of neuroradiology each month for 42 months. Errors included (1) not calling for a CF, (2) not identifying a CF as such, (3) mischaracterizing non-CFs as CFs, and (4) calling for non-CFs. The number of appropriately handled and mishandled reports in each month was recorded. The trend of error reduction after the division chief provided feedback in the subsequent months was evaluated, and the equality of time interval between errors was tested.
  
  
  RESULTS
  Among 2,100 reports, 49 (2.3%) were handled inappropriately. Among non-CF reports, 98.97% (1,817 of 1,836) were appropriately not called and not flagged, and 88.64% (234 of 264) of CF reports were called and flagged appropriately. The error rate during the 11th through 32nd months of review (1.28%) was significantly lower than the error rate in the first 10 months of review (3.98%) (P = .001). This benefit lasted for 21 months.
  
  
  CONCLUSIONS
  Review and giving feedback to radiologists increased their compliance with the CF protocol and decreased deviations from standard operating procedures for about 2 years (from month 10 to month 32). Developing new ideas for improving CF policy compliance may be required at 2- to 3-year intervals to provide continuous quality improvement.
authors: Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors: Mona
authors: M
authors: Shahriari
authors: Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
authors: Li
authors: L
authors: Liu
authors: Division of Neuroradiology, The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Medical Institutions, Baltimore, Maryland. Electronic address: dyousem1@jhu.edu.
authors: David M
authors: DM
authors: Yousem
mesh_terms: D003142:Communication; D003951:Diagnostic Errors / Q000517:prevention & control*; D006801:Humans; D059906:Neuroimaging / Q000592:standards*; D058996:Quality Improvement; D011873:Radiology Information Systems; D013997:Time Factors
keywords: Critical findings; communication; notification; quality improvement