Averting a betrayal of trust: System and individual accountability in healthcare infection prevention

Abstract

Television crime plots are formulaic-a body is discovered in an unexpected place, foul play is suspected, evidence is collected, and detectives work to piece together clues. Just as the episode is about to end, the final clue is discovered, revealing the perpetrator. With the criminal caught and jailed, justice ensues and public trust is restored. When a patient is harmed in healthcare, assigning blame is rarely that simple. Each year healthcare-associated infections (HAIs) harm 1 in 31 inpatients; HAIs lead to~99,000 preventable patient deaths in the United States annually. 1 Who do we hold accountable for these incidents of harm? Unlike on television, harm in healthcare rarely results from a single bad actor. Healthcare organizations historically held providers accountable for cases of medical harm, but following the landmark report, "To Err Is Human: Building a Safer Health System," focus shifted to system failures as key contributors to adverse events. 2 Researchers noted that after years of a punitive approach to clinician errors, this "no blame" movement was widely embraced, and new systems solutions were developed to improve safe healthcare delivery. 3 Continuing research supports a just culture framework, one in which a complex landscape of systemic and individual factors contributes to patient harm with shared accountability. 4 Researcher Derick W. Brinkerhoff describes accountability as "the obligation of individuals or agencies to provide information about, and/or justification for, their actions to other actors, along with the imposition of sanctions for failure to comply and/or to engage in appropriate action." 5 Tisné et al state, "Broadly speaking, accountability refers to the process of holding actors responsible for their actions. More specifically, it is the concept that individuals, agencies and organizations (public, private and civil society) are held responsible for executing their powers according to a certain standard (whether set mutually or not)." 6 Defining and practicing accountability is emphasized in patient safety cultures, and continuing research suggests accountability may influence the success of infection prevention strategy. At a large tertiary-care facility, establishing an individual hand hygiene accountability program resulted in improved hand hygiene compliance and decreased device-associated standardized infections. 7 These findings suggest that individual accountability may

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