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

Choksi, Vaishali R; Marn, Charles; Piotrowski, Marcia M; Bell, Yvonne; Carlos, Ruth · J Am Coll Radiol · 2005

review · Level V

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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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