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J Am Coll Radiol. 2005 Sep;2(9):768-76.

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

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

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.

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PMID:
17411925
DOI:
10.1016/j.jacr.2005.01.013
[Indexed for MEDLINE]

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