title: Accountability for medical error: moving beyond blame to advocacy.
abstract: Accountability in medicine, once assigned primarily to individual doctors, is today increasingly shared by groups of health-care providers. Because patient safety experts emphasize that most errors are caused not by individual providers, but rather by system breakdowns in complex health-care teams, individual doctors are left to wonder where their accountability lies. Increasingly, teams deliver care. But patients and doctors alike still think of accountability in individual terms, and the law often measures it that way. Drawing on an example of delayed lung cancer diagnosis, we describe the mismatch between how we view errors (systems) and how we apportion blame (individuals). We discuss "collective accountability," suggesting that this construct may offer a way to balance a "just culture" and a doctor's specific responsibilities within the framework of team delivery of care. The concept of collective accountability requires doctors to adopt transparent behaviors, learn new skills for improving team performance, and participate in institutional safety initiatives to evaluate errors and implement plans for preventing recurrences. It also means that institutions need to prioritize team training, develop robust, nonpunitive reporting systems, support clinicians after adverse events and medical error, and develop ways to compensate patients who are harmed by errors. A conceptual leap to collective accountability may help overcome longstanding professional and societal norms that not only reinforce individual blame and impede patient safety but may also leave the patient and family without a true advocate.
authors.affiliation: Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. Electronic address: Sbell1@bidmc.harvard.edu.
authors.forename: Sigall K
authors.initials: SK
authors.lastname: Bell
authors.affiliation: Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
authors.forename: Tom
authors.initials: T
authors.lastname: Delbanco
authors.affiliation: Clinical Ethics Consult Service, University of Illinois at Chicago, Chicago, IL.
authors.forename: Lisa
authors.initials: L
authors.lastname: Anderson-Shaw
authors.affiliation: Departments of Anesthesiology and Pediatrics, University of Illinois at Chicago, Chicago, IL.
authors.forename: Timothy B
authors.initials: TB
authors.lastname: McDonald
authors.affiliation: Departments of Medicine, Bioethics, and Humanities, University of Washington, Seattle, WA.
authors.forename: Thomas H
authors.initials: TH
authors.lastname: Gallagher
mesh_terms: D057210:Delayed Diagnosis; D006739:Hospital Administration; D006801:Humans; D016365:Liability, Legal; D019300:Medical Errors / Q000517:prevention & control; D016749:National Practitioner Data Bank; D015279:Organizational Culture; D010344:Patient Advocacy; D010348:Patient Care Team; D012449:Safety; D012941:Social Responsibility; D014481:United States