Who's to Blame?

摘要

There is a second tragedy at St. Mary's Hospital that is scarcely hinted at in the otherwise excellent report by Smetzer et al. of the investigation and response to a terrible fatal medication error. That tragedy is what happened to the nurse who made the error, Julie Thao, whom the hospital blamed for the mishap and fired. Not only was this action calamitous for Julie, but if the hospital had taken institutional responsibility at the outset, the criminal indictment and loss of licensure might not have occurred. Julie was truly a second victim in more ways than one.rnBut blaming is a normal response, and in this kind of situation entirely predictable. Someone must be at fault when something this gross and this tragic occurs. "'Fess up and take your punishment," we cry. But if we substitute the less inflammatory word accountability for blame, the appropriate answer becomes more obvious.