Abstract
Modern diagnostic imaging often yields unexpected malignancy findings （UMFs）. If proper follow-up is not ensured, these findings pose a severe risk to patient safety due to a disconnect between reading the electronic report and taking clinical action. To guarantee appropriate clinical decision-making, our institution implemented a “closed-loop communication” system. In this system, the patient safety department actively tracks cases using a ledger, thereby complementing the communication between the radiologist and the ordering physician. This study retrospectively analyzed the effectiveness of this healthcare professional-driven active tracking system for UMFs, aiming to verify its consistency with international quality metrics and to clarify the effectiveness of third-party intervention in completing closed-loop communication. The analysis included 148 UMF cases from the registry （April 2022-July 2025）. The primary endpoints, which are consistent with American College of Radiology （ACR） metrics, included time to initial contact, the ordering physician’s acknowledgment status at the time of contact （documented in 117 cases）, and the final outcome. The median time to initial contact was 1 day, with 94％ of contacts made within 3 days. However, 60.7％ of the cases were unacknowledged and unaddressed at initial contact. Despite this, the system achieved successful final outcomes: 98％ of all patients accessed proper medical care, including surgery （38％） and consultation with other specialties （37％）. The study concludes that the active tracking system effectively achieves both rapid contact and appropriate, successful outcomes, despite a high initial rate of unacknowledged cases. This finding aligns with international studies on the management of actionable incidental findings （AIFs）. The system is considered a reproducible internal standard operating procedure for other facilities through technological integration （RIS/PACS） and stepwise escalation notification.
