Balancing "no blame" with accountability in patient safety.

n engl j med 362;3 nejm.org january 21, 2010 275 To the Editor: Wachter and Pronovost (Oct. 1 issue)1 question the “no-blame” paradigm in patient-safety improvement and suggest the adoption of explicit punitive approaches to poorly performing physicians. We counsel caution. In a longitudinal study over a 2-year period in a large facility,2 we found that penalties did not deter undesirable behavior. Rather, penalties drove evidence of noncompliance underground, encouraging people to conceal it and thus perversely reducing accountability. Drawing the line between blameworthy and blameless acts was difficult and involved subjective judgments of observers about the foreseeability of harm, reasonable care, and prudence. The question was: Who was permitted to draw that line?3 And who reported “violations”? In the example of hand hygiene described in the article, those difficulties are compounded by uncertainties in the evidence base about when and how hands should be washed.4 In our study, peer intervention was more effective in generating accountability and desired change than punitive administrative action; less blame led to more accountability. Our research clearly suggests that by demanding penalties, we might stifle accountability rather than enhance it.