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Medical Ethics |

Accountability for Medical ErrorCollective Accountability for Medical Error: Moving Beyond Blame to Advocacy FREE TO VIEW

Sigall K. Bell, MD; Tom Delbanco, MD; Lisa Anderson-Shaw, DrPH; Timothy B. McDonald, MD, JD; Thomas H. Gallagher, MD
Author and Funding Information

From the Department of Medicine (Drs Bell and Delbanco), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; the Clinical Ethics Consult Service (Dr Anderson-Shaw) and the Departments of Anesthesiology and Pediatrics (Dr McDonald), University of Illinois at Chicago, Chicago, IL; and the Departments of Medicine, Bioethics, and Humanities (Dr Gallagher), University of Washington, Seattle, WA.

Correspondence to: Sigall K. Bell, MD, Beth Israel Deaconess Medical Center, Division of Infectious Diseases, 110 Francis St, LMOB-GB, Boston, MA 02215; e-mail: Sbell1@bidmc.harvard.edu


Editor’s note: This review addresses the 14th topic in the core curriculum of the ongoing Medical Ethics series. To view all articles included in the Medical Ethics series, visit http://chestjournal.chestpubs.org/cgi/collection/medethics.

Constantine A. Manthous, MD, FCCP, Section Editor, Medical Ethics

Funding/Support: Dr Gallagher’s work on this article was supported by the Robert Wood Johnson Foundation Investigator Award in Health Policy Research, the Agency for Healthcare Research and Quality [1R01HS016506, R18HS01953], and the Greenwall Foundation. Dr McDonald’s work was supported by the Agency for Healthcare Research and Quality [r18HSO19565].

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(2):519-526. doi:10.1378/chest.10-2533
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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.

You are the office pulmonologist and primary care physician (PCP) for a 71-year-old patient hospitalized Friday afternoon for an exacerbation of COPD. For 3 days he receives IV steroids, antibiotics, bronchodilators, supplemental oxygen, and supportive measures. The admission chest film reports “high suspicion of left upper lobe suprahilar nodule. Recommend CT scan with contrast to evaluate.” On Friday night, this critical test result is called to the attention of the resident managing the patient, and she documents this finding in a progress note in the electronic health record. On Monday morning, the patient goes home, scheduled to see you in follow-up. In the body of the discharge summary, the suspicious lesion is noted, but you receive no direct communication about the abnormal findings, and the discharge instructions do not indicate the need for follow-up CT scan. No one tells the patient or his family about the finding.

Much improved a month later, the patient comes to see you. You review the discharge summary conclusions and recommendations, but miss the reference to the pulmonary lesion in the body of the document. Six months later, the patient arrives dyspneic in the ED. The chest film shows enlargement of the left upper lobe density, and CT scan suggests a malignancy. Biopsy results yield squamous cell carcinoma, and the patient undergoes surgical excision and a course of radiation therapy.

Upon learning of the patient’s delayed diagnosis, you review the chest film from the prior hospitalization and learn for the first time of the suspicious lesion. You return to the discharge summary and confirm the absence of any mention of the radiology results or follow-up recommendations in the summary section. Torn between the desire to keep an open and trusting relationship with the patient and the fear of being sued, you wonder if and how to tell the patient about this earlier result. You also wonder what else (if anything) you should do to keep errors like this from happening again.

When a patient experiences a harmful medical error, such as a delayed diagnosis of cancer, questions of accountability naturally arise. Did this patient suffer from “bad apples,” bad systems, or some combination? How should the PCP/pulmonologist in this case view his individual accountability for the delayed cancer diagnosis, and what specific responsibilities does he hold? What are the institution’s responsibilities in this case and how do they complement the doctor’s role?

Increasingly, patient safety experts seek the right balance between individuals and systems. Rhetoric abounds, with some suggesting that the concept of just culture1 can help promote individual accountability within a systems framework.2 But assigning responsibility for medical errors in the systems era can be elusive. Who “owns” the system?

Accountability is a term used with increasing frequency in health care. It has a variety of meanings, including considerations of who is responsible and what we are responsible for when things go wrong. We define accountability for adverse events and medical error as a set of expectations for the appropriate response to harmed patients, derived from ethical norms, patients’ preferences,3 and principles of patient safety. Accountability in this context includes (1) transparency (ie, reporting the event to the institution and disclosing/apologizing to the patient/family), (2) preventing recurrences by fixing the underlying problem at the institutional level following root cause analyses, and (3) providing appropriate patient compensation.

Around since at least the 1980s,4 and revisited this century by Sharpe5 and Ashcroft,6 is the intriguing notion of “collective accountability,” a concept in which all providers, in concert with health-care institutions, work collaboratively to share responsibility for transparency, error prevention, and “making the patient whole.” Bringing collective accountability to life is complex but may ultimately benefit patients and clinicians. We take care of patients as teams, we err as teams, and we need a way to accept accountability as teams.7

Stemming from the first American Medical Association8 code of ethics in 1847, the notion that there is “no tribunal, other than [the doctor’s] own conscience” gave rise to the intense self-scrutiny that has followed doctors into the 21st century. Still socialized in a take-the-blame culture,9 doctors are urged from the first days of training to step up to the plate and own sole responsibility for their patients,10 even though today’s care is delivered by many health-care providers.

The practice environment has fostered such thinking. For much of the history of medicine, doctors functioned predominantly in solo practices as independent providers, leading them naturally to develop an insular mindset, a deep and intense focus centered entirely on the patient in front of them as compared to the larger community of patients served by a given hospital or health-care institution. When errors occurred, incompetent or lazy providers, dubbed “bad apples,” were to blame. The key to quality improvement was finding and removing the bad apples, and the inevitable consequence of this strategy was to hide errors and limit transparency.11

But today the pendulum is swinging from the individual to the system. Increasing system complexity often plays a larger role in errors than the individual practitioner, and the Institute of Medicine urges health professionals to look beyond the smoking gun to the system if they hope to make meaningful changes in patient safety.12 Without doubt, patient safety in today’s health care environment relies on the coordination, input, and vigilance of many moving parts. Multiple providers, frequent hand-offs, and complex interactions make it virtually impossible for a single doctor to own all the events involved in an individual patient’s care.10 Delivering a single medicine may involve as many as six steps or pass-offs.13 For the Boston Globe reporter who died after receiving four times the intended dose of chemotherapy, the erroneous medication order passed through the hands of nearly 25 health-care providers.14

Yet survey studies suggest that doctors are divided about the notion that defective systems, not individual doctors, are responsible for most medical errors.15 To some extent, doctors’ skepticism may reflect uncertainty about what is meant by “system error.” The term has become a catch phrase for everything other than individual error, including a collection of individuals, faulty equipment, systems of training, duty hours, or the coincidental alignment of permissive events and inadequate barriers, as in Reason’s “Swiss cheese model.”16 Ill-defined in concept, system error lacks precision in terms of accountability; in fact, it does not address accountability at all, leaving doctors confused about their individual responsibility when a system breaks down.

In addition, although patient safety pedagogy underscores a systems-based root cause for most errors, societal norms and today’s malpractice system generally hold individual providers accountable for patient injuries, even when they reflect serious systems errors.17 Had the patient in our index case sued, he likely would have sued the PCP/pulmonologist, the last identifiable link in the chain of causation, despite the reality that many other contributing factors beyond the individual doctor’s control contributed to the delayed diagnosis. Even in cases in which a patient sues both individual providers and the institution, doctors face potential penalties that may far exceed the institutional burden. A doctor who is successfully sued faces the potential inability to find affordable malpractice insurance, loss of license, barriers to hospital privileges, and in extreme (but rare) cases, a threat to personal assets if the judgment exceeds their policy limits. Our perspectives on patient safety and accountability are incongruent: the system errs, but the individual often pays most.

Perhaps because many doctors are uncertain of the role of system breakdowns (and accountability), as opposed to individual responsibility, in medical errors, they cling to a “captain of the ship” mentality and are relatively unengaged in institutional patient safety programs.18 Might this be partly responsible for the limited progress in reducing adverse events and errors? Although there have been notable exceptions, such as central line-associated bloodstream infections,19 the rate of many high profile errors, such as wrong site surgeries and retained foreign bodies, is largely unchanged.20-22

The bottom line is that as the delivery of medicine has evolved to increasingly complex health-care systems, patient safety concepts have shifted from individuals to systems, but societal (and doctors’) perceptions of accountability have not. This mismatch is not only confusing to clinicians but also a detriment to patient safety. Returning to our case, we are left without a clear answer to the question: Who is accountable for the delayed cancer diagnosis?

An approach to patient safety through collective accountability tries to bridge the gap between system and individual responsibility. Introduced more than 25 years ago, it is not a shield from individual accountability, but rather puts “each and every one of [us] ‘on call.’”4 For the PCP/pulmonologist in this case, collective accountability would require seeking to meet the needs of this injured patient, first by openly disclosing the error to the patient and the institution, despite his ambivalence about doing so. It would also call on all the doctors involved in the case to engage actively with the health-care system to uncover the causes of this delayed diagnosis and to participate proactively in institutional patient safety efforts stemming from the error. Finally, it would entail team training and communication skills activities for all doctors to prevent future errors.

What about the institution? The primary focus of institutional accountability often centers on public reporting of health-care outcomes. But collective accountability would also call on this institution to answer to poorly designed health records, nonstandardized hand-offs of information, inadequate abnormal-result follow-up, and faulty discharge processes,23,24 immediate and critical responses to this case that would not necessarily result from the patient suing the doctor or the hospital. Other institutional responsibilities in a collective accountability framework include developing robust nonpunitive reporting systems, supporting clinicians after adverse events and medical error, and developing ways to compensate patients who are harmed by system errors. Organizations should also enforce maintenance of competency (perhaps by linking such requirements to institutional credentialing), ensure adherence to quality benchmarks and evidence-based medicine, and develop mechanisms to identify and rehabilitate impaired clinicians.25,26

We already engage in some models of collective accountability. For example, greater scrutiny of hand-off processes27 and team activities like time-outs encourages each clinician to examine more closely not only his own but also his team member’s actions.22 Strengthening and standardizing hand-offs can help ensure that things go right. Next steps require similar collective processes when things go wrong. As discussions about accountable care organizations gain attention,28-31 collective accountability may become a mechanism for such organizations to approach shared responsibility.

Why should time-constrained doctors take on additional responsibilities? Finding a better solution for accountability in the systems era, so that blame does not fall disproportionately on the shoulders of individual providers, would be more fair and could make it more likely that doctors will be active participants in system-level patient safety efforts. As Wachter notes in an article by Chen,18 “Patient safety can’t happen if physicians aren’t smack in the middle of it. We can either facilitate safety or we can stand in its way.”

In addition to improving patient safety, clinicians may also benefit from institutional resources and tools that accompany a greater focus on collective accountability. For example, institutional resources such as disclosure coaches and peer support after adverse events can help clinicians better meet the needs of patients who are injured by medical care,32 while also supporting the needs of the involved clinicians.33 Institutions focused on collective accountability will also have a heightened commitment to respond with meaningful change to health-care workers’ reports of adverse events. In addition, guidelines and practices emerging from responses to errors or near-misses will be more relevant to doctors on the “sharp end” (front line) if doctors themselves, rather than administrators, actively help shape them. And more eyes on the system engender enhanced detection of near misses.

But perhaps the most compelling reason to broaden our focus beyond our individual patients to the broader population of patients served by our institutions, even beyond our civic duties34 or ethical grounds of nonmalfeasance,35 is that our patients are asking us to do so. When things go wrong, patients place enormous value on knowing what will be done to prevent a similar incident from happening again.3,20,36-38 They specifically want to see hospital-wide improvements in safety practices.3,38 Collective accountability enables providers to meet such patient expectations by engaging all involved providers to think carefully about system solutions that will prevent the same pitfall for another patient (and doctor).22 It also allows clinicians to advocate more effectively for their own individual patients by collaborating with institutions to assist with patient compensation.

When things go wrong, institutional programs that compensate patients fairly for harmful errors, a direct extension of collective accountability, can help physicians advocate for their patients with reduced conflicting fear of litigation. New disclosure and offer programs39 already offer different mechanisms for providing compensation to patients following medical injuries and may help doctors reconsider their historical reluctance to advocate for their patients in the area of compensation. Data from initiatives at the University of Michigan suggest favorable outcomes for patients and institutions.40-42 In the case example, the doctor was, in fact, torn between the desire to maintain an open, trusting relationship with his patient and the hope that the patient would never discover that the lesion was known long before he acted on it. Disclosure and offer programs may help avoid the counterproductive silence and secrecy following errors that currently impede patient safety efforts in the tort system. They may free doctors from the inherent conflict between meeting the patient’s needs and the self-preservation that often complicates the response to error, allowing doctors to step forward more actively as advocates for their patients.

Lack of Consensus

Substantial barriers impede implementation of collective accountability. First, we lack consensus about what the specific responsibilities of individual doctors, institutions, and even patients should be for patient safety. To move forward, all involved will need to acknowledge such uncertainty and begin a dialogue about what collective accountability means. The issues are not simple. Examples include whether and how to disclose other providers’ mistakes, whether and how to engage patients and their families actively in patient safety initiatives, and how to manage power dynamics in team accountability and disclosures.

Medical Culture

Medical culture, the set of values, hierarchies, and expectations embedded in the profession, is itself a barrier to collective accountability, especially when it is related to open discussion about mistakes. Historically, individual error has been seen as a moral failure,5,43 and doctors have been trained with the unspoken assumption of physician infallibility, the strong internalized message that doctors cannot, and do not, make mistakes.44 Although attitudes about discussing error are improving, we still need to change the messages (explicit and hidden) with which we train doctors if we expect them to share their mistakes or point out those of others. Pervasive hierarchic frameworks, a strong culture of individualism, and lack of adequate psychological safety for reporting represent strong disincentives to speaking up.45,46 And even if providers are willing to report errors, they may refrain from doing so if they feel reporting will not result in meaningful institutional change. The consequence? From the perspective of system improvements, many events engender no more than silence.47

In addition, solving problems on the systems level remains far from the forefront of many providers’ minds.15 The legacy of solo practice and its logical cousin, the “insular” mind, may inhibit doctors from taking an active role in a larger system. Extreme time constraints in the modern clinical environment limit system learning from problems as they arise, because pressed clinicians are more likely to seek quick fixes to the immediate problems of their individual patients.48-50 They are also less likely to ask for help, having been trained in a system where doing so is a sign of weakness.

Responsibility, Liability, and Name-Based Reporting

Some critics fear that a model of shared accountability will diffuse responsibility, allowing no one to feel responsible,51 and encourage doctors to blame the system or “get a free ride.”52 Others argue that the pendulum has already swung too far away from individual responsibility. Using hand hygiene as an example, these experts suggest that although system factors are important (eg, ensuring adequate access to hand sanitizer dispensers in all clinical areas), individual health-care workers should be accountable when they violate standards of safe practice by failing to use these dispensers.2

On the other hand, charitable immunity at some not-for-profit hospitals may skew this balance disproportionately toward individual responsibility.53 In these cases, patients harmed by systems errors may be inclined to pursue the deeper pockets of individual providers. The balance may also be particularly precarious in settings in which separate malpractice insurance carriers represent the providers and the hospital. If our case occurred in the nonacademic setting, achieving appropriate patient compensation would be more complicated: How much would the hospital’s carrier pay and how much would the pulmonologist’s carrier pay? Doctors may be advised to avoid discussing the case with other potential litigants, including the hospital and other providers, reinforcing secrecy and provider isolation while inhibiting patient safety and collective accountability.

Reporting to the National Practitioner Data Bank (NPDB) and state licensing board, a contentious issue generally, also has important implications for collective accountability. The potential benefits of collective accountability may be tempered quickly in those states in which individual doctors involved in a systems error still face a culture of shame and blame through name-based reporting at the state licensing board, especially if they step forward (as now taught routinely in disclosure training programs) and accept responsibility (together with the institution) for harm done. Because the NPDB does not require the reporting of doctors named in a claim but dropped from the settlement, some institutions have provided a corporate shield to their doctors in cases that are due to systems errors and have settled the claim solely in the name of the institution.42,54 Richard C. Boothman, JD, chief risk officer at the University of Michigan Health System, emphasizes the need to keep individual doctors “safe but accountable” (personal communication, March 2011). We believe that this approach to NPDB reporting is one example of striking that difficult balance.

Additional Barriers

Other barriers abound: Everyone is too busy. Leaders for these efforts are few and far between. There is no firm evidence that collective accountability will improve patient safety, although the concept is promising. And the need for tort reform looms large, triggering some to feel that until the overwhelming task of malpractice reform is addressed, it is pointless for providers to tackle initial steps to change the views of the profession and society on accountability.

Overcoming barriers to collective accountability will require both culture change and new resources. From the first days of medical school, emphasis on team training and collegial, respectful relationships with nurses and other health-care professionals will send the message that medicine is no longer an individual sport.55 Turning to other industries (eg, aviation, automobile production, nuclear power, education), this time with a focus on achieving collective accountability (in addition to safety), can help establish more advanced frameworks for responsibility.56,57 Patients, too, can be critically important teachers. Although recent data help us understand patient perspectives when mistakes are made,3,58 much less is known about the patient’s potential role in ensuring that things go right.59 Inviting patients to work as collaborators in both designing safer systems and assuring collective accountability is a logical next step.

Collective accountability will require creativity. What innovative metrics can doctors and institutions develop to judge the responsibilities of individuals within systems? How can a group of individuals “think” like the system and catch (and correct) errors when they happen in the space between individuals, as in our index case? And finally, obtaining buy-in from doctors, who are always juggling multiple demands, will necessitate providing time, support, and, in some instances, academic credit.60 As outlined by others who have called on doctors to expand their professional obligations as “physician-citizens,” success in advancing collective accountability will require clarity of purpose, effective actions, and reasonable limits.34

For the concept of collective accountability to reach its full potential, changes in the approach to practitioner reporting may be needed at the state and federal levels. State Board of Medicine and federal NPDB reporting requirements should be revised to more accurately reflect the role of system breakdowns in medical injury, reserving individual, name-based reporting for errors of individual gross negligence. Some argue that institutions (as well as state and federal legislatures) also need to reconsider the relative liability of institutions (vs individuals) in medical errors that are found to be systems based.61

The PCP in this case initially responded with the “my problem, my responsibility” individual accountability mindset. He agonized over the missed, embedded text about the suspicious lesion in the discharge summary without stopping to ask, “Why doesn’t my hospital have a system to help avoid such mistakes?”

The PCP was a significant part of the chain of events causally connected to the unfortunately delayed cancer diagnosis. But the PCP did not cause the event in isolation. Collective accountability for the involved doctors might look like this: The PCP discloses the delayed diagnosis openly and directly to the patient and reports the problem in communication and data transfer between inpatient and outpatient spheres to the institution. The inpatient attending of record and resident are notified of the downstream events in the patient’s care and, together with the PCP and institutional leadership, participate directly in system fixes to prevent such a mistake from happening again. The PCP advocates for the patient by participating in the event analysis to uncover the root causes of the delayed diagnosis and implement prevention plans. He also helps advance the patient’s interests by supporting collaborative efforts between the institution and the malpractice insurer to offer appropriate compensation to the patient. Finally, all the clinicians involved become active participants in learning about system improvement on a day-to-day basis, reporting near misses, improving team communication skills, and applying the mentality of shared ownership for patient safety to daily practice.

Although these suggestions can help frame specific responsibilities for doctors and institutions involved in medical error, perhaps the more important message is to recognize that the systems approach to medical error has left important unanswered questions about accountability, and focused work is needed to define collective accountability in each of our own divisions, departments, and institutions. Ultimately, striking the right balance between individuals and systems in any given health-care system will depend on medical staff and organizational leadership coming together and reaching such consensus. Although collective accountability appeared in the literature over a quarter of a century ago, we still lack a clear understanding of the individual doctor’s responsibilities within a system framework. If another delayed cancer diagnosis were to happen tomorrow, the involved doctor might similarly either fall on the sword and take personal blame for the error, or feel lost in the system, assuming no accountability at all. Can we enhance a culture of safety with a culture of collective accountability and reengage doctors as full advocates for their patients? Developing clearly defined accountability standards and expectations for doctors participating in team-based care is critical for improving patient safety and for restoring doctors as true advocates for their patients.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsors had no role in the design of the study, the collection and analysis of the data, or in the preparation of the manuscript.

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Tucker A, Edmondson AC, Spear SJ. When problem solving prevents organizational learning. J Organ Change Manage. 2002;152:122-137. [CrossRef]
 
Tucker A, Edmondson AC. Managing routine exceptions: a model of nurse problem solving behavior. Advances in Health Care Management. 2002;3:87-113
 
Sharpe VESharpe VE Accountability: Patient Safety and Policy Reform. 2004; Washington, DC Georgetown University Press
 
Wolfe S. Bad doctors get a free ride. New York Times. March 4, 2003;
 
NGA Center for Best PracticesNGA Center for Best Practices Addressing the medical malpractice insurance crisis. National Governors Association Web site.http://www.nga.org/cda/files/1102medmalpractice.pdf. 2002. Accessed December 31, 2010.
 
Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5-240-W5-249
 
Nance J. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. 2008; Bozeman, MT Second River Healthcare Press
 
Pronovost PJ, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;283:w479-w489. [CrossRef] [PubMed]
 
Arens SA. Examining the meaning of accountability: reframing the construct. McREL Issues Brief.2005:1-12
 
Delbanco T, Bell SK. Guilty, afraid, and alone–struggling with medical error. N Engl J Med. 2007;35717:1682-1683. [CrossRef] [PubMed]
 
20 Tips to help prevent medical errors: patient fact sheet. Agency for Healthcare Research and Quality Web site.http://www.ahrq.gov/consumer/20tips.htm. 2000. Accessed December 17, 2010.
 
Shojania KG, Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine. JAMA. 2009;3017:766-768. [CrossRef] [PubMed]
 
Sage WM, Hastings KE, Berenson RA. Enterprise liability for medical malpractice and health care quality improvement. Am J Law Med. 1994;201-2:1-28. [PubMed]
 

Figures

Tables

References

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Henriksen K, Dayton E. Organizational silence and hidden threats to patient safety. Health Serv Res. 2006;414 Pt 2:1539-1554. [CrossRef] [PubMed]
 
Tucker A, Edmondson AC. Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003;452:55-72
 
Tucker A, Edmondson AC, Spear SJ. When problem solving prevents organizational learning. J Organ Change Manage. 2002;152:122-137. [CrossRef]
 
Tucker A, Edmondson AC. Managing routine exceptions: a model of nurse problem solving behavior. Advances in Health Care Management. 2002;3:87-113
 
Sharpe VESharpe VE Accountability: Patient Safety and Policy Reform. 2004; Washington, DC Georgetown University Press
 
Wolfe S. Bad doctors get a free ride. New York Times. March 4, 2003;
 
NGA Center for Best PracticesNGA Center for Best Practices Addressing the medical malpractice insurance crisis. National Governors Association Web site.http://www.nga.org/cda/files/1102medmalpractice.pdf. 2002. Accessed December 31, 2010.
 
Chandra A, Nundy S, Seabury SA. The growth of physician medical malpractice payments: evidence from the National Practitioner Data Bank. Health Aff (Millwood). 2005;Suppl Web Exclusives:W5-240-W5-249
 
Nance J. Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. 2008; Bozeman, MT Second River Healthcare Press
 
Pronovost PJ, Goeschel CA, Olsen KL, et al. Reducing health care hazards: lessons from the commercial aviation safety team. Health Aff (Millwood). 2009;283:w479-w489. [CrossRef] [PubMed]
 
Arens SA. Examining the meaning of accountability: reframing the construct. McREL Issues Brief.2005:1-12
 
Delbanco T, Bell SK. Guilty, afraid, and alone–struggling with medical error. N Engl J Med. 2007;35717:1682-1683. [CrossRef] [PubMed]
 
20 Tips to help prevent medical errors: patient fact sheet. Agency for Healthcare Research and Quality Web site.http://www.ahrq.gov/consumer/20tips.htm. 2000. Accessed December 17, 2010.
 
Shojania KG, Levinson W. Clinicians in quality improvement: a new career pathway in academic medicine. JAMA. 2009;3017:766-768. [CrossRef] [PubMed]
 
Sage WM, Hastings KE, Berenson RA. Enterprise liability for medical malpractice and health care quality improvement. Am J Law Med. 1994;201-2:1-28. [PubMed]
 
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