Who's to Blame? Attitudes on Accountability for Patient Safety Lapses

Laura A. Stokowski, RN, MS


January 06, 2014

In This Article

Responding to Clinicians Who Fail to Follow Patient Safety Practices: Perceptions of Physicians, Nurses, Trainees, and Patients

Driver TH, Katz PP, Trupin L, Wachter RM
J Hosp Med. 2013 Dec 17. [Epub ahead of print]

Shifting and Reshifting the Blame

In the years following the Institute of Medicine's landmark report, To Err is Human: Building a Safer Health System,[1] the field of patient safety and medical error prevention underwent a material change. Gone were the days of punitive reactions to incident reports, as healthcare institutions gradually shifted to a "blame-free" approach to error. This approach relied heavily on the notion that systems, rather than individuals, were responsible for error, and that errors were learning opportunities to improve safety within the entire facility. Education was the chief remedial action, and personal responsibility played a minor role in the new patient safety paradigm.

Now, the pendulum might have swung too far from individual accountability for a failure to follow established patient safety protocols. New questions have been raised about how healthcare institutions should deal with healthcare providers who repeatedly flaunt safety protocols, such as hand hygiene. Should they be punished? If so, how many infractions are enough to justify punishment? How do healthcare providers and patients feel about these issues?

A study by Driver and colleagues provides some preliminary answers to these questions. Researchers at the University of California, San Francisco (UCSF), administered a survey to a convenience sample of physicians (attending physicians and residents), medical students, nurses, and patients that posed 3 clinical scenarios involving a healthcare provider who committed a patient safety protocol lapse:

  • Failure to properly conduct hand hygiene before a patient encounter;

  • Failure to conduct a fall risk assessment on a hospitalized patient; and

  • Failure to conduct a preoperative time-out before surgery.

These patient safety scenarios were selected because they were supported by strong evidence, were considered relatively easy and inexpensive to perform, and were associated with significant patient harm. Respondents were asked to rate the level of potential harm to patients when these lapses occurred.

Respondents were also asked to consider the appropriateness of a variety of responses to patient safety lapses, ranging from direct feedback to the individual (email feedback, verbal feedback, meeting with a supervisor, quarterly performance review meeting, and quarterly report card seen only by the provider), reporting the individual's infractions on a public Website, or administering penalties (fines, suspension without pay, or termination). Finally, respondents were asked how many cases of documented nonadherence were enough to justify penalties to the individual who failed to follow these safety protocols, including whether such penalties were "ever appropriate."


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