Balancing “No Blame” with Accountability in Patient Safety

This year marks the 10th anniversary of the Institute of Medicine’s report To Err Is Human,1 the document that launched the modern patient-safety movement. Although the movement has spawned myriad initiatives, its main theme, drawn from studies of other high-risk industries that have impressive safety records, boils down to this: Most errors are committed by good, hardworking people trying to do the right thing. Therefore, the traditional focus on identifying who is at fault is a distraction. It is far more productive to identify error-prone situations and settings and to implement systems that prevent caregivers from committing errors, catch errors before they cause harm, or mitigate harm from errors that do reach patients.2,3 Most health care providers embraced the “no blame” model as a refreshing change from an errors landscape previously dominated by a malpractice system that was generally judged as punitive and arbitrary. And this shift has unquestionably borne fruit. For example, rather than trying to perfect doctors’ handwriting and memories, computerized systems catch medication errors before they reach patients.4 Implementing simple checklists markedly increases the use of evidencebased prevention strategies, leading to fewer surgical complications and bloodstream infections associated with central venous catheters.5,6 But beginning a few years ago, some prominent health care leaders began to question the singular embrace of the “no blame” paradigm. Leape, a patient-safety pioneer and early proponent of systems thinking,2 described the need for a more aggressive approach to poorly performing physicians,7 and the Joint Commission has made addressing the problem of disruptive caregivers a priority.8 Goldmann identified the need to create accountability for failure to perform hand hygiene.9 Rather than a “no blame” culture, Marx promoted a “just culture,” which differentiates blameworthy from blameless acts.10,11 Many health care organizations (including our own) have recognized that a unidimensional focus on creating a blame-free culture carries its own safety risks. But despite this recognition, finding the appropriate balance has been elusive, and few organizations have implemented meaningful systems of accountability, particularly for physicians. In this article, we describe some of the barriers to physician accountability, enumerate patient-safety practices that are ready for an accountability approach, and suggest penalties for the failure to adhere to such practices. We focus on situations in which the action (or inaction) of individual physicians poses a clear risk to patients, rather than on the broader issues of clinical competence or disruptive behavior; readers who are interested in the latter issues are referred to other sources.7,12,13