Helen Kuhl, ITN Editor

Helen Kuhl is Editorial Director of Imaging Technology News.

Blog | Helen Kuhl, ITN Editor | September 16, 2011

Kate’s Words of Wisdom

As I was writing this month’s column, I ran across a quote attributed to Catherine the Great, who said, “I praise loudly, I blame softly.” Coincidentally, the words echoed a topic I planned to discuss, inspired by a program on radiation safety I attended during the recent annual meeting of the American Association of Physicists in Medicine – namely, that one way to reduce medical radiation errors in imaging facilities is to adopt a culture encouraging personnel to report mistakes without fingerpointing.

Another apt phrase to express this message is, “No blame, no shame” — the words used by William R. Hendee, Ph.D., a professor at the Medical College of Wisconsin and Marquette University, who led the AAPM program I attended. I am more accustomed to thinking about radiation safety from the systems side, where adjustments are made to equipment and software to achieve lower dose and improve safety. But Hendee and other speakers, like Brenda Clark, M.D., Ottawa Hospital Cancer Center in Ottawa, Ont., Canada, focused on the human side, which is the point I found interesting.

Clark noted that no matter how well someone is trained, human error is inevitable. When it happens, she said the key is to ask, “Why did this happen?” and take corrective action.

Such error management  requires a workplace atmosphere in which people feel comfortable owning up to their mistakes. This can take concerted effort to achieve, especially when our culture fosters more of a “cover-your-butt,”  “it’s not my problem” or “it was the other guy’s fault” mentality.  

The need for such a culture also is recognized by Lawrence B. Marks, M.D., professor at the University of North Carolina. In an article that appeared earlier this year in PRO, the American Society for Radiation Oncology’s journal, he said, “Our field needs to better understand the frequency and causes of errors, especially those with the potential to do harm. We also need to incorporate basic human-factor principles that minimize risks into the design of our workspaces and services.”

As Marks alluded, minimizing human error should not be left to chance. It is something that can be improved by establishing rules or protocols that create favorable conditions for minimizing the possibilities for mistakes.

”Safety is a management concern,” Clark said in her program. Commitment from leaders is critical to the success of such efforts, she added.

Clark and Hendee were speaking about radiation safety from a radiotherapy point of view. Interestingly, a newly released alert from the Joint Commission that focuses on safety in diagnostic radiation contains similar points. Among actions the Joint Commission recommends for facilities to reduce risks due to avoidable diagnostic radiation, is to promote a culture of safety.

There are numerous steps facilities can and should take to eliminate opportunities for mistakes as much as possible. But getting back to the words of the Russian empress — in the (hopefully) rare instances when human error does occur, whether or not that mistake happens again may depend greatly on whether or not that human being feels comfortable coming forward to help fix whatever needs fixing, then and there. If there is a “blame softly” culture, it should help.
 

Related Content

Researchers Awarded 2018 Canon Medical Systems USA/RSNA Research Grants
News | Radiology Imaging | November 13, 2018
The Radiological Society of North America (RSNA) Research & Education (R&E) Foundation recently announced the...
Charles Ananian, M.D.

Charles Ananian, M.D.

Sponsored Content | Case Study | Digital Radiography (DR) | November 07, 2018
Whether it’s a premature baby or a critically ill child, treating little patients is a huge responsibility.
Results of the vertebrae-based analysis (383 vertebrae in 34 patients) for detection of BME.

Results of the vertebrae-based analysis (383 vertebrae in 34 patients) for detection of BME.

Sponsored Content | Case Study | Computed Tomography (CT) | November 06, 2018
The following is a summary of a study published in the
An example of the newest generation of smart cardiac CT software that automatically identifies the anatomy, autotraces the centerlines on the entire coronary tree and labels each vessel segment.

An example of the newest generation of smart cardiac CT software that automatically identifies the anatomy, autotraces the centerlines on the entire coronary tree and labels each vessel segment. This greatly speeds CT workflows, saving time for techs, radiologists and cardiologists.

Feature | Radiology Imaging | October 04, 2018 | By Dave Fornell
Here is a checklist of dose-sparing practices for cardiac computed tomography (CT) imaging used in the cath lab.
Philips Launches Ingenia Ambition X 1.5T MR
News | Magnetic Resonance Imaging (MRI) | September 14, 2018
September 14, 2018 — Philips announced the launch of the Ingenia Ambition X 1.5T...
Videos | Radiation Therapy | September 07, 2018
A discussion with Ehsan Samei, Ph.D., DABR, FAAPM, FSPIE, director of the Duke University Clinical Imaging Physics Gr
Videos | Radiomics | August 09, 2018
A discussion with Martin Vallieres, Ph.D., post-doctoral fellow at McGill University, Montreal, Canada.
Gary D. Luker Named Editor of Radiology: Imaging Cancer

Image courtesy of University of Michigan Medical School

News | Oncology Diagnostics | August 06, 2018
The Board of Directors of the Radiological Society of North America (RSNA) announced that Gary D. Luker, M.D., will...
Videos | Digital Radiography (DR) | August 03, 2018
Sheila Sferrella, president of Regents Health Resources and Bill Finerfrock, president of Capitol Associates, discuss
Videos | AAPM | August 03, 2018
Ehsan Samei, Ph.D., DABR, FAAPM, FSPIE, director of the Duke Un...