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Marx D. New York, NY: Columbia University; 2001.
Accountability is a concept that many wrestle with as they steer their organizations and patients toward understanding and accepting the idea of a blameless culture within the context of medical injury. Marx presents the concept from the legal perspective but does so for the non-barrister. Written prior to the acceptance of open disclosure or general policy support of it, the primer thoughtfully outlines the complex nature of deciding how best to hold individuals accountable for mistakes. Four key behavior concepts serve as the structure for the paper: human error, negligence, reckless conduct, and knowing violations. How they are applied to various situations in health care and how the individuals involved should be disciplined provide thoughtful reading.
Dekker S. Boca Raton, FL: CRC Press; 2016. ISBN: 9781472475787.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.
Journal Article > Study
Rosenstein AH, O'Daniel M. Jt Comm J Qual Patient Saf. 2008;34:464-471.
This survey of clinicians and managers from more than 100 hospitals revealed that unprofessional behavior is common among both physicians and nurses. Respondents strongly agreed that disruptive behavior adversely affects patient safety and the quality of care, and the authors recommend various approaches that hospitals can implement to address communication and behavioral problems. A prior commentary discussed system-level solutions to addressing unprofessional behavior, and guidelines have been formulated to identify and address such issues. The concept of just culture has been proposed in order to maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur as a result of system flaws.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
Journal Article > Study
Gallagher TH, Mello MM, Levinson W, et al. N Engl J Med. 2013;369:1752-1757.
Physicians are notably loath to fully disclose their own errors, but some progress is being made in this area due to institutional policies supporting error disclosure. This article is intended to foster discussion of an especially thorny issue: how clinicians should approach error disclosure when the error was committed by a colleague. As little prior literature exists regarding this dilemma, the authors emphasize a patient-centered approach that begins with a respectful peer-to-peer conversation and does not shirk the need to fully disclose the error. The importance of institutional support, particularly in establishing a just culture that promotes error disclosure, is also emphasized. The article's lead author, Dr. Thomas Gallagher, was interviewed by AHRQ WebM&M in 2009.