I have been thinking about this a lot recently.
I believe in a culture of safety and creating a blame free environment in which errors are assessed as part of a system failure. This generally holds true. But the system is not always to blame, accountability cannot be overlooked.
I dug up this paper (NEJM full text) from 2006-system failure versus personal accountability, by Donald Goldmann.
A more recent perspective, hot off the press, on leadership oversight for safety programs can be found here. The authors hit the nail on the head. Accountability by leaders is a critical element of a safety program.
When the vast majority of providers can complete evidence based safety measures such as wash hands, complete check lists, perform time outs, bathe patients etc, those who refuse to play by the rules generally are not victims of the system.
In a addition to a primed system, high reliability in patient safety requires leadership, which requires accountability, which at times requires tough discussions and tough decisions.
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| Source: cnbc.com |
I believe in a culture of safety and creating a blame free environment in which errors are assessed as part of a system failure. This generally holds true. But the system is not always to blame, accountability cannot be overlooked.
I dug up this paper (NEJM full text) from 2006-system failure versus personal accountability, by Donald Goldmann.
A more recent perspective, hot off the press, on leadership oversight for safety programs can be found here. The authors hit the nail on the head. Accountability by leaders is a critical element of a safety program.
When the vast majority of providers can complete evidence based safety measures such as wash hands, complete check lists, perform time outs, bathe patients etc, those who refuse to play by the rules generally are not victims of the system.
In a addition to a primed system, high reliability in patient safety requires leadership, which requires accountability, which at times requires tough discussions and tough decisions.
