Employees empowered through teamwork to prevent errors

Radiation therapy staff are expert planners. Patients with cancer visit the Hallmark Health System (HHS) Radiation Therapy Department
several days before they actually begin radiation treatments. The goal is precision – to ensure that radiation is delivered to the exact area needed and no other. At HHS, the radiation therapy team consists of administrative staff, nurses, physicist, dosimetrists, radiation therapists and radiation oncologists. “The physicist and dosimetrists are the ‘architects’ of treatment, who draw the blueprint for clinicians to use during treatment,” said Glenn Davis, HHS operations manager for Oncology.

Last summer, one of the dosimetrists noticed a discrepancy among the pieces of documentation for a patient’s planned treatment.
“It was a left side/right side issue,” said Davis, “and, had it not been spotted, the patient could have received radiation on the wrong
side.” The dosimetrist spoke up, asked for clarification to resolve which side was the target and submitted a “near miss” RMPro report.
The key phrase here is “spoke up.” “Because everyone on the radiation therapy team feels empowered to speak up – in the interests
of process improvement instead of individual blame – the mistake was caught and no harm was done,” said Davis.

And the key concept is teamwork. “No one is better than anyone else on our team,” he added. “We are all responsible for the series of
checks and double-checks – through software, checklists and other tools – that ensure the quality of our work. And we are all very
comfortable about raising questions and concerns when patient safety is at stake.”


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