Despite a growing awareness ofthe system-based causes oferrors, many in health care arestill struggling with the role of individualaccountability in a nonpunitive just culture.We ask, "How can we hold individualsaccountable for their actions withoutpunishment?" Some even suggestedthat such an approach to error reductioncould lead to increased carelessness aspeople learn that they will not be punishedfor their mistakes. Our experiencehas shown, however, that staff awarenessof safety issues and enthusiasm forchanging systems and practices associatedwith errors grows in a just culturesystem. Therefore, a system-basedapproach to error reduction does notdiminish accountability; it redefines itand directs it in a much more productivemanner by focusing on the most manageablecomponent of the error: the systemitself.
Typically, only those individuals at the"sharp end" of an error (where the practitioner-patient interaction occurs) areheld accountable. We must shift fromthis thinking and realize that accountabilityshould be shared among all healthcare stakeholders. Each individual inhealth care must become accountable,not for zero errors, but for incorporatingpatient safety into every aspect of his orher job. In addition, we all becomeaccountable for identifying safety problems,implementing system-based solutions,as well as inspiring and embracinga culture of safety.
Because we are not capable of practicingwithout making errors, health carepractitioners should be held accountablefor speaking out about patient safetyissues, voluntarily reporting potential andactual errors, as well as hazardous situations,and for sharing personal knowledgeof what went wrong when an erroroccurs. Also, practitioners must beempowered to ask for help when needed,consistently provide patient education,and be willing to change their practicesto enhance safety.
Health care management should beheld equally accountable for making itsafe and rewarding for practitioners toopenly discuss errors and patient safetyissues. They must hold regular safetybriefings with staff to learn about improvementneeds, discuss strategic plans,and identify new potential sources oferror. When practitioners recommenderror-prevention strategies, managementmust support them and provide themeans necessary within a reasonabletime frame to implement system enhancementsto improve efficiency andsafety. Management should be heldaccountable for understanding and addressingbarriers to safe practice, such asdistractions and unsafe workloads.Management should incorporate patientsafety as a value in the organization's missionand engage the community and staffin proactive continuous quality improvementefforts, including an annual selfassessmentof patient safety. All healthcare personnel should be held accountablefor working together as a team, notas autonomous individuals. Finally, managementand staff alike need to reviewand share safety literature frequently andoffer visible support to their colleagueswho have been involved in errors.
This model of shared accountabilitygoes beyond individual health care settingsto encompass licensing, regulatory,and accrediting bodies; government; professionalschools; professional associations;public policy makers; manufacturersand vendors; and the public at large.For example, licensing and regulatorybodies should be held accountable foradopting standards related to error-reductionrecommendations that arise fromexpert analysis of adverse events and scientificresearch. Educators should seekout patient safety information and use it incurriculum design. Professional organizationsshould support local and nationalreporting systems and disseminateimportant patient safety information totheir members. Manufacturers and softwarevendors should be held accountablefor pre-and postmarket evaluation andcontinuous improvement in the design ofdevices and products as well as labels andpackages.
A model of shared accountabilityrequires all who interact with the healthcare system to help to define its weaknessesand find ways to make it stronger.Organizational leaders and other stakeholderswho simply hold the workforceaccountable when an error happens areinappropriately delegating their ownresponsibility for patient safety.We mustaccept a model of shared accountability.Implementing solutions and inspiring andembracing a just culture to reach thegoal of safety may not be easy, but it iscertainly necessary.
Dr. Gaunt is a medication safety analyst and the editor of ISMPMedication Safety Alert! Community/Ambulatory Care Edition.
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