Editor’s Notebook – Personal Accountability: The Next Frontier

By Susan Carr
Editor, susan.psqh@gmail.com

The patient safety movement is now 20 years old, if we tie its origin to publication of “Error in Medicine” by Lucian Leape, MD, in 1994. The movement has evolved, with an expanding agenda, deeper research, and increasing numbers of people from all walks of healthcare devoting themselves to improvement. At the National Patient Safety Foundation’s (NPSF) annual Patient Safety Congress in May, speakers referred to the movement’s having “matured” as they proposed a new focus: personal accountability.

During a lively and collegial debate, Bob Wachter, MD, and Gregg Meyer, MD, faced off over the question of whether it is better to punish individuals for patient safety “transgressions” or to maintain a blame-free approach that looks only to the system for root causes. The question was overly black and white but launched a thoughtful discussion. The prevailing view held that most safety events are caused by flawed systems and that individuals must be held accountable when they repeatedly act in ways known to put patients at risk.

Wachter cited low hand hygiene rates in hospitals where the system—availability of sanitizer dispensers, sinks, and reminders—is quite good. At some point, the system becomes a scapegoat for irresponsible behavior. He added historical perspective by observing that establishing a “blame-free” culture was important in the early days of patient safety in order to enlist as many people as possible, especially physicians. Wachter observed that failing to hold individuals accountable when it’s appropriate means that “we’ve all become enablers” and said, “It’s time to recalibrate our approach.”

During another keynote session at NPSF’s Congress, Kaveh Shojania, MD, also discussed accountability as he reviewed selected papers that advanced the science of patient safety in the past year. In one of those papers, researchers found a tiny minority of physicians—a few “bad apples”—accounted for a large percentage of 18,000 complaints filed over 11 years across Australia. Specifically, 3% of physicians accounted for 50% of complaints, and 1% accounted for 25% (Bismark et al., 2013). This work reinforces research done by Gerald Hickson, MD (http://www.mc.vanderbilt.edu/centers/cppa/index.php). We have known for years that disruptive behavior is toxic to patients and co-workers alike, but progress has been slow.

Wachter, Shojania, and others encourage the patient safety community to take a new look at accountability while continuing to work on system improvement. Strong leadership will be even more important to this effort than to other safety initiatives because holding people accountable is difficult, and it is crucial to get it right. Wachter points out that failure to self-regulate sends a message to everyone, including patients, that other interests trump safety. Failure to self-regulate invites external regulation. It’s time to tackle this challenge.


Bismark, M.M, Spittal, M. J., Gurrin, L. C., Ware, M., & Studdert, D. M. (2013, April 10). Identification of doctors at risk of recurrent complaints: A national study of healthcare complaints in Australia. BMJ Quality & Safety. http://qualitysafety.bmj.com/content/early/2013/02/22/bmjqs-2012-001691.full

Leape L. (1994). Error in medicine. JAMA, 272, 1851-1857.