Re: Queries: ROOT CAUSE

[Michael Kay <mikekay@teleport.com>]

Dick King wrote:
> 
> > Date: Wed, 19 Feb 1997 15:59:38 +0000
> > From: "Frank "Free Spirit" Borger" <frank@rover.bsd.uchicago.edu>
> > Subject: Re: Queries
> >
> >       The fault lies  not with the physician, but with the
> >       education process, for not giving physicians tools to
> >       enable them to make logical decisions.
> >
> 
> Bleah.
> 
> Nothing was stopping the physician from saying "let me check on that" and
> hunting up a radiation safety professional, if he had doubts rather than
> "knowing" wrong "facts".
> 
> -dk

Welcome to a chapter from life in the real world:

Have you people ever done accident or incident investigation? There are
both surface and root causes for an accident or incident. The surface
cause in this case is the potentially criminal lack of knowledge by the
physician in question. But that is only the surface cause. In almost all
cases (this is really as close to an "every" as you can get-Ive never
found an exception), addressing only the surface cause will not prevent
future accidents or incidents from happening in the same way. You need
to address the underlying generic problem--radiophobia

Root causes always go back the the system, be it management,
supervision, procedures, protocols, purchasing, etc. In this case, it is
quite clear that the system is at fault for imbuing such fear, even in
educated individuals. I would classify it as Inadequate Training, and
the root cause of the inadequate training is the untoward fear of
radiation, even in those who are providing the training. And those who
write and provide the training are directly influenced by the
radiophobic groups that set the standards that are so low it is easy to
scare everybody. It is not until that root cause is addressed that you
will have any chance of providing adequate training and influencing
decisions and behavior up the line.

Michael A. Kay, ScD, CHMM
mikekay@teleport.com