Re: Queries: ROOT CAUSE

[rkathren@tricity.wsu.edu (Ron L. Kathren)]

Michael --

Maybe we ought to blame the woman for getting pregnant; that seems like a
logical root cause.  Or perhaps it's all traceable to Adam and Eve for
begetting.  This is not analagous to an accident investigation, and I think
Frank Borger has hit the nail on the head.  Of course, there may be more
than one nail .  .  .  In any case, we must assume some responsibility for
our actions.

Ron Kathren

>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
>
>