Accountability: Challenges to Getting It Right

Abstract

Patient safety experts debated accountability in health care at the 2014 annual National Patient Safety Foundation Congress. The debate reflected the struggles organizations are facing with ensuring a responsible workforce committed to patient safety versus the need to redesign flawed systems that are error prone. The question, "is it the systems or the individual?" was at issue. This article proposes that it is the wrong question, and the failure to apply patient safety science in clinical practice is contributing to the ambiguity fueling the debate. To transform accountability from a source of confusion to a powerful tool for fulfilling health care's fiduciary responsibility to protect patients from harm, we need to reframe our approach. This article presents the science and strategies to create clarity that will redirect the dialogue from a debate in which accountability resides to one about learning for improvement when adverse events occur.

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

“…However, overindividualised feedback, particularly if summative rather than formative, cultivated a blame culture that acted as a barrier to quality improvement and audit cycle completion 93–95. This reflects findings from other empirical studies and highlights the importance of emphasising collective, institutional accountability rather than personal accountability 92 96–98. While the approach to and efficacy of feedback varied, the requirement for facilitated action planning accompanying it in order to generate positive clinical change was a reproducible finding.…”

The space to make mistakes: allocating responsibility and accountability for nursing student-committed medication errors

“…This acknowledgement that there may be justifiably shared responsibility and accountability is a key feature of a just culture, in which individuals understand that they will be held accountable for their actions but will not be blamed for system factors outside of their control . As has been suggested as ideal by Aveling et al (2016) and Duthie (2018), students in this study clearly sought that just culture rather than one that reflected a purely systems-based approach or a purely person-based approach. However, a just culture approach was not what they typically experienced, and students therefore perceived the culture of blame as still entrenched within the healthcare system.…”

“…Still other authors have separated some of these preconditions according to who holds accountability for them. For example, the accountability of an individual practitioner will be related to decisions that they made in the clinical situation while organizational accountability will be related to the resources provided by that organization to allow an individual practitioner to provide safe patient care (Duthie, 2018).…”

“…Goldmann (2006) and Croskerry (2010) emphasize that, if we wish to make healthcare safer for patients, then we need to find the most effective balance between a pure person-based approach to errors and a pure systems-based approach. In other words, a just culture is what should be sought (Aveling et al, 2016;Barnsteiner & Disch, 2012;Dekker, 2009a;Duthie, 2018). However, it must also be noted that, while the safety literature recommends that individuals be held accountable for decisions that they make and for their own problematic practices, there is currently limited evidence available to demonstrate such accountability in clinical practice (Duthie, 2018).…”