The competent surgeon: individual accountability in the era of 'systems' failure.

摘要

"he IOM report of 1998 "To Err is Human" prompted a near frenzy of attention to patient safety, hardly a novel concept.1 Actually, the line from Pope's original essay, of course, reads "To err is human, to forgive divine" and while we are all certainly human, it is the forgiving part with which we have had trouble.2 It is one thing to forgive; quite another to ignore. We are now far more knowledgeable regarding the magnitude of medical error.3 To that end, a major focus of the patient safety initiative centered on implementing "systems" designed to minimize the risk of "individual" failure. Yet, I would submit that the pendulum may have swung too far from individual accountability. The notions of the "blame-free environment" and a "nonpunitive culture" have crept into our everyday vocabulary reflecting a noble effort to encourage open reporting of adverse events, the first step toward designing a strategy to reduce error. That preoccupation with "the system," however, tends to exonerate individual responsibility. Wrong-sided or wrong-site surgery still occurs with regularity in spite of the time-outs and checklists. Medication error incidents have been dramatically reduced, but not eliminated, with the implementation of electronic systems. There is an increasing awareness that disruptive behavior continues to adversely impact the safe care of our patients and the workplace environment.