n engl j med 361;14 nejm.org october 1, 2009 1401 sounding board The new england journal of medicine Balancing “No Blame” with Accountability in Patient Safety Robert M. Wachter, M.D., and Peter J. Pronovost, M.D., Ph.D. This year marks the 10th anniversary of the In- stitute of Medicine’s report To Err Is Human, 1 the document that launched the modern patient-safety movement. Although the movement has spawned myriad initiatives, its main theme, drawn from studies of other high-risk industries that have im- pressive safety records, boils down to this: Most errors are committed by good, hardworking peo- ple trying to do the right thing. Therefore, the traditional focus on identifying who is at fault is a distraction. It is far more productive to identify error-prone situations and settings and to imple- ment systems that prevent caregivers from com- mitting errors, catch errors before they cause harm, or mitigate harm from errors that do reach patients. 2,3 Most health care providers embraced the “no blame” model as a refreshing change from an errors landscape previously dominated by a mal- practice system that was generally judged as pu- nitive and arbitrary. And this shift has unquestion- ably borne fruit. For example, rather than trying to perfect doctors’ handwriting and memories, computerized systems catch medication errors be- fore they reach patients. 4 Implementing simple checklists markedly increases the use of evidence- based prevention strategies, leading to fewer sur- gical complications and bloodstream infections associated with central venous catheters. 5,6 But beginning a few years ago, some promi- nent health care leaders began to question the singular embrace of the “no blame” paradigm. Leape, a patient-safety pioneer and early proponent of systems thinking, 2 described the need for a more aggressive approach to poorly performing physicians, 7 and the Joint Commission has made addressing the problem of disruptive caregivers a priority. 8 Goldmann identified the need to create accountability for failure to perform hand hy- giene. 9 Rather than a “no blame” culture, Marx promoted a “just culture,” which differentiates blameworthy from blameless acts. 10,11 Many health care organizations (including our own) have recognized that a unidimensional fo- cus on creating a blame-free culture carries its own safety risks. But despite this recognition, finding the appropriate balance has been elusive, and few organizations have implemented mean- ingful systems of accountability, particularly for physicians. In this article, we describe some of the barriers to physician accountability, enumerate patient-safety practices that are ready for an ac- countability approach, and suggest penalties for the failure to adhere to such practices. We focus on situations in which the action (or inaction) of individual physicians poses a clear risk to patients, rather than on the broader issues of clinical com- petence or disruptive behavior; readers who are interested in the latter issues are referred to other sources. 7,12,13 “No Blame” versus Accountability A decade ago, rates of hand hygiene in most Amer- ican hospitals were shameful, often below 20%. As attention began to focus on unacceptably high rates of health care–associated infections, most organizations treated low hand-hygiene rates as a systems problem. 14 Many launched “hand hy- giene campaigns,” accompanied by internal dis- semination of hand-hygiene rates and admonitions by senior administrators to improve the rates (sometimes accompanied by financial incentives). Hand-gel dispensers were placed in or near every patient’s room. A few institutions even brought in human-factors engineers to assess the overall hand-hygiene system and recommend process changes. To the degree that the failure to clean hands was due to flawed systems or provider ig- norance, these actions made sense. Despite these efforts, most hospitals continue to have hand-hygiene rates that range from 30 to 70%, and few have sustained rates over 80%. We have had the experience of asking frustrated hos- Copyright © 2009 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org at UC SHARED JOURNAL COLLECTION on October 29, 2009 .