Illustrating the Root-Cause-Analysis Process: Creation of a Safety Net with a Semiautomated Process for the Notification of Critical Findings in Diagnostic Imaging
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.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Electronic alerts have been shown to improve critical lab results communication in the inpatient setting.
“Electronic “alerts” have been shown to improve critical lab results communication in the inpatient setting, and they show promise in improving the safety of outpatient test result follow-up.45,52,53”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [53]
Electronic alerts show promise in improving the safety of outpatient test result follow-up.
“Electronic “alerts” have been shown to improve critical lab results communication in the inpatient setting, and they show promise in improving the safety of outpatient test result follow-up.45,52,53”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [53]
Cites
Wall, A. (2000) · British Journal of Healthcare Management · doi:10.12968/bjhc.2000.6.9.19311 · Cited by 5,909 · see citing works
Incidence of Adverse Events and Negligence in Hospitalized Patients
Brennan, T. A., Leape, L. L., Laird, N. M., Hebert, L. E., Localio, A. R., Lawthers, A. G., Newhouse, J. P., Weiler, P. C., & Hiatt, H. H. (1991) · New England Journal of Medicine · doi:10.1056/nejm199102073240604 · Cited by 4,631 · see citing works
The Nature of Adverse Events in Hospitalized Patients
Leape, L. L., Brennan, T. A., Laird, N. M., Lawthers, A. G., Localio, A. R., Barnes, B. A., Hebert, L. E., Newhouse, J. P., Weiler, P. C., & Hiatt, H. H. (1991) · New England Journal of Medicine · doi:10.1056/nejm199102073240605 · Cited by 3,766 · see citing works
Adverse events in British hospitals: preliminary retrospective record review
Vincent, C. A., Neale, G., & Woloshynowych, M. (2001) · BMJ · doi:10.1136/bmj.322.7285.517 · Cited by 2,075 · see citing works
Incidence and Types of Adverse Events and Negligent Care in Utah and Colorado
Thomas, E. J., Studdert, D. M., Burstin, H. R., Orav, E. J., Zeena, T., WILLIAMS, E. J., Howard, K., Weiler, P. C., & Brennan, T. A. (2000) · Medical Care · doi:10.1097/00005650-200003000-00003 · Cited by 1,673 · see citing works
From the Joint Commission on Accreditation of Healthcare Organizations
Loeb, J. M. (1996) · JAMA · doi:10.1001/jama.275.7.508 · Cited by 1,521 · see citing works
Brown, A. B., & Patterson, D. A. (2001) · Cited by 1,396 · see citing works
A primer on leading the improvement of systems: Fig 1
Berwick, D. M. (1996) · BMJ · doi:10.1136/bmj.312.7031.619 · Cited by 793 · see citing works
Estimating Hospital Deaths Due to Medical Errors
Hayward, R. A., & Hofer, T. P. (2001) · JAMA · doi:10.1001/jama.286.4.415 · Cited by 589 · see citing works
(2018) · CRC Press eBooks · doi:10.1201/9780203751725 · Cited by 573 · see citing works
Medical error: the second victim
Wu, A. W. (2000) · Western Journal of Medicine · doi:10.1136/ewjm.172.6.358 · Cited by 477 · see citing works
Eden, C. (1978) · Futures · doi:10.1016/0016-3287(78)90074-5 · Cited by 424 · see citing works
[Incidence of adverse events in hospitals. A retrospective study of medical records].
Schiøler, T., Lipczak, H., Pedersen, B. L., Mogensen, T., Bech, K., Stockmarr, A., Svenning, A. R., & Frølich, A. (2001) · PubMed · Cited by 315 · see citing works
Fitzgerald, R. H. (2001) · Clinical Radiology · doi:10.1053/crad.2001.0858 · Cited by 243 · see citing works
Adverse Events in New Zealand Public Hospitals: Principal Findings from a National Survey
Davis, P. B., Lay‐Yee, R., Briant, R., Schug, S. A., Scott, A., Johson, S., & Bingley, W. (2003) · UWA Profiles and Research Repository (UWA) · Cited by 149 · see citing works
Communicating Findings of Radiologic Examinations
Berlin, L. (2002) · American Journal of Roentgenology · doi:10.2214/ajr.178.4.1780809 · Cited by 109 · see citing works
Accident analysis of large-scale technological disasters applied to an anaesthetic complication
Eagle, C., Davies, J. M., & REASON, J. T. (1992) · Canadian Journal of Anesthesia/Journal canadien d anesthésie · doi:10.1007/bf03008640 · Cited by 101 · see citing works
Grasha, A. F. (2000) · American Journal of Health-System Pharmacy · doi:10.1093/ajhp/57.6.554 · Cited by 37 · see citing works
Chakraverty, S., & Wright, J. (2001) · PubMed · Cited by 33 · see citing works
Continuous quality improvement for radiologists1
Applegate, K. E. (2004) · Academic Radiology · doi:10.1016/s1076-6332(03)00670-6 · Cited by 32 · see citing works
Foreword: Preventing Medical Accidents: Is “Systems Analysis” The Answer?
Leape, L. L. (2001) · American Journal of Law & Medicine · doi:10.1017/s0098858800011448 · Cited by 21 · see citing works
Reed, C. (2005) · Scientific American · doi:10.1038/scientificamerican0205-24 · Cited by 15 · see citing works
Statute of Limitations and the Continuum of Care Doctrine
Berlin, L. (2001) · American Journal of Roentgenology · doi:10.2214/ajr.177.5.1771011 · Cited by 9 · see citing works
Flagged first, then by citations
Cited by
Sorted by citations
Singh, H., Naik, A. D., Rao, R., & Petersen, L. A. (2008) · Journal of General Internal Medicine · doi:10.1007/s11606-007-0393-z · Cited by 162 · see citing works
Communication outcomes of critical imaging results in a computerized notification system
Singh, H., Arora, H. S., Vij, M. S., Rao, R., Khan, M. M., & Petersen, L. A. (2007) · Journal of the American Medical Informatics Association · doi:10.1197/jamia.m2280 · Cited by 140 · see citing works
- Authors
- Choksi, V. R., Marn, C., Piotrowski, M. M., Bell, Y., & Carlos, R.
- Affiliations
- VA Ann Arbor Healthcare System (US)
- University of Michigan (US)
- ORCID
- Carlos, Ruth
- Venue
- Journal of the American College of Radiology
- Publisher
- Elsevier BV
- Published
- 2005-09
- Volume
- 2
- Issue
- 9
- Pages
- 768-776
- ISSN
- 1546-1440 (ISSN-L)
- OpenAlex
- W2009572339
- Cited by
- 28
- References
- 23
- Citations by year
- 2026: 1 · 2025: 1 · 2024: 2 · 2023: 1 · 2021: 1 · 2020: 2 · 2017: 1 · 2016: 2 · 2015: 2 · 2014: 1 · 2012: 2
- FWCI
- 1.78
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of the American College of Radiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Radiology, Nuclear Medicine and Imaging › Radiology practices and education
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
- Keywords
- root cause analysis, diagnostic imaging, social safety nets, medical errors, patient safety
- MeSH terms
- Diagnostic Imaging, Humans, Lung Neoplasms, Male, Middle Aged, Quality of Health Care, Radiography, Radiology Department, Hospital, United States, Critical Illness, Safety Management, Disease Notification, Risk Assessment, Incidental Findings, Healthcare Common Procedure Coding System
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
