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Medical Ethics |

Accountability for Medical ErrorCollective Accountability for Medical Error: Moving Beyond Blame to Advocacy

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.


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