The effectiveness of a radiology quality and patient safety program is enhanced by an ongoing understanding of prevailing errors. Many tools are available to assist in analyzing errors and understanding their cause, but this understanding cannot happen unless errors are revealed in the first place. Staff members are often reluctant to reveal their own or others’ mistakes if they fear adverse consequences or potential disciplinary action. Unfortunately, this is the case in many practices today. Although adverse events may ultimately come to light when patient harm occurs, even under those circumstances, less consequential errors or near misses may remain hidden, and future patients remain at risk.
A just culture is an environment in which errors and near-miss events are evaluated in a deliberately nonpunitive framework, avoiding a culture of blame and responsibility and focusing instead on error prevention and fostering a culture of continuous quality improvement. Adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to build a culture of safety.
Here are some resources designed to assist facilities and groups on establishing just culture, using peer-learning as an expression of just culture for radiologists, and implementing peer-learning best practices.
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