Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging

Vaishali R Choksi; Charles Marn; Marcia M Piotrowski; Yvonne Bell; Ruth Carlos

doi:10.1016/j.jacr.2005.01.013

Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging

J Am Coll Radiol. 2005 Sep;2(9):768-76. doi: 10.1016/j.jacr.2005.01.013.

Authors

Vaishali R Choksi¹, Charles Marn, Marcia M Piotrowski, Yvonne Bell, Ruth Carlos

Affiliation

¹ Department of Veterans Affairs, Ann Arbor VA Healthcare System, Ann Arbor, MI 48109-0030, USA. vrchoksi@med.umich.edu

PMID: 17411925
DOI: 10.1016/j.jacr.2005.01.013

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.

Publication types

Case Reports
Review

MeSH terms

Critical Illness
Diagnostic Imaging / standards*
Disease Notification / standards*
Healthcare Common Procedure Coding System*
Humans
Incidental Findings
Lung Neoplasms / diagnostic imaging*
Male
Middle Aged
Quality of Health Care
Radiography
Radiology Department, Hospital
Risk Assessment
Safety Management
United States