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Introduction
Of the many vexing problems in patient safety, none are trickier than balancing the 'no blame' systems approach to medical errors with the need for accountability-at the individual, managerial and organisational levels. Informed by the pioneering work of Professor James Reason, 1 2 the patient safety field embraced the former approach in its early years-both because it is largely correct (most errors are, in fact, committed by good people trying their very best) and because it was politically expedient. In the USA particularly, where mentioning 'medical errors' to a doctor immediately evokes near-Pavlovian thoughts of being named in a malpractice suit, the 'no blame' approach represented the only hope to engage physicians in safety efforts.
While 'systems thinking' has led to many improvements in safety (eg, computerised order entry, bar coding, standardisation and simplification of processes, and improved equipment design), it tells an incomplete story. Specifically, a 'no blame' approach seems apt for some errors but not others; the latter category includes errors committed by incompetent, intoxicated or habitually careless clinicians, or by those unwilling to follow reasonable safety rules and standards.
This recognition has led to efforts over the past few years to balance 'no blame' and accountability. This rebalancing gained momentum as both the US and UK healthcare systems enacted policies to promote institutional, if not individual, accountability for performance. In the USA, such policies include more aggressive hospital accreditation requirements by the Joint Commission, as well as public reporting of safety hazards, 'no pay for errors' initiatives, and 'Value-Based Purchasing' by Medicare. 3 4 In the UK, accountability has been promoted by incentive-based payments for general practitioners and high-profile investigations by the Care Quality Commission on reported safety lapses in individual hospitals. 5 6
This paper highlights the tension between 'no blame' and accountability. It reflects on the value and limitations of the 'Just Culture' paradigm, and explores the role of personal versus organisational accountability.
A representative case
Scott Torrence, a 36-year-old insurance broker, was struck in the head while going up for a rebound during his weekend basketball game. Over the next few hours, a mild headache escalated into a thunderclap, and he became lethargic and vertiginous. His girlfriend called an ambulance to take him to the emergency room in...