The New Emphasis on Quality and Safety

摘要

This issue of JACR contains an article by Choksi et al on the process known as "root-cause analysis." Root-cause analysis is mandated by the Joint Commission on Accreditation of Healthcare Organizations in the circumstance of a morbidity-inducing or mortality-inducing event caused by human error. The process is intended to use the lessons learned from medical errors to improve systems so that similar errors are less likely to occur in the future. The authors make a compelling case for the virtues of root-cause analysis and provide an interesting example pertinent to radiology.