Despite a growing awareness of the system-based causes of errors, many in health care are still struggling with the role of individual accountability in a nonpunitive just culture. We ask, "How can we hold individuals accountable for their actions without punishment?" Some even suggested that such an approach to error reduction could lead to increased carelessness as people learn that they will not be punished for their mistakes. Our experience has shown, however, that staff awareness of safety issues and enthusiasm for changing systems and practices associated with errors grows in a just culture system. Therefore, a system-based approach to error reduction does not diminish accountability; it redefines it and directs it in a much more productive manner by focusing on the most manageable component of the error: the system itself.
Typically, only those individuals at the "sharp end" of an error (where the practitioner-patient interaction occurs) are held accountable. We must shift from this thinking and realize that accountability should be shared among all health care stakeholders. Each individual in health care must become accountable, not for zero errors, but for incorporating patient safety into every aspect of his or her job. In addition, we all become accountable for identifying safety problems, implementing system-based solutions, as well as inspiring and embracing a culture of safety.
Because we are not capable of practicing without making errors, health care practitioners should be held accountable for speaking out about patient safety issues, voluntarily reporting potential and actual errors, as well as hazardous situations, and for sharing personal knowledge of what went wrong when an error occurs. Also, practitioners must be empowered to ask for help when needed, consistently provide patient education, and be willing to change their practices to enhance safety.
Health care management should be held equally accountable for making it safe and rewarding for practitioners to openly discuss errors and patient safety issues. They must hold regular safety briefings with staff to learn about improvement needs, discuss strategic plans, and identify new potential sources of error. When practitioners recommend error-prevention strategies, management must support them and provide the means necessary within a reasonable time frame to implement system enhancements to improve efficiency and safety. Management should be held accountable for understanding and addressing barriers to safe practice, such as distractions and unsafe workloads. Management should incorporate patient safety as a value in the organization's mission and engage the community and staff in proactive continuous quality improvement efforts, including an annual selfassessment of patient safety. All health care personnel should be held accountable for working together as a team, not as autonomous individuals. Finally, management and staff alike need to review and share safety literature frequently and offer visible support to their colleagues who have been involved in errors.
This model of shared accountability goes beyond individual health care settings to encompass licensing, regulatory, and accrediting bodies; government; professional schools; professional associations; public policy makers; manufacturers and vendors; and the public at large. For example, licensing and regulatory bodies should be held accountable for adopting standards related to error-reduction recommendations that arise from expert analysis of adverse events and scientific research. Educators should seek out patient safety information and use it in curriculum design. Professional organizations should support local and national reporting systems and disseminate important patient safety information to their members. Manufacturers and software vendors should be held accountable for pre-and postmarket evaluation and continuous improvement in the design of devices and products as well as labels and packages.
A model of shared accountability requires all who interact with the health care system to help to define its weaknesses and find ways to make it stronger. Organizational leaders and other stakeholders who simply hold the workforce accountable when an error happens are inappropriately delegating their own responsibility for patient safety.We must accept a model of shared accountability. Implementing solutions and inspiring and embracing a just culture to reach the goal of safety may not be easy, but it is certainly necessary.
Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/Ambulatory Care Edition.
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