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.


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