As I have emphasized throughout this book, the fundamental underpinning of the modern patient safety field is “systems thinking”—the notion that most errors are made by competent, caring people, and that safe care therefore depends on embedding providers in systems that anticipate errors and block them from causing harm. That is an attractive viewpoint, and undoubtedly correct in the main. But it risks causing us to avert our eyes from those providers or institutions who, for a variety of reasons, are not competent, or worse.

After last chapter’s discussion of the malpractice system—the most visible, but often dysfunctional, incarnation of accountability in healthcare—this chapter focuses on more subtle issues, including “Just Culture,” dealing with disruptive providers, and the role of the media in patient safety. At its heart, the chapter aims to address one of the most challenging questions in patient safety: can our desire for a “no blame” culture, with all its benefits, be reconciled with the need for accountability?

Scott Torrence, a 36-year-old insurance broker, was struck in the head while going up for a rebound during his weekend basketball game. Over the next few hours, a mild headache escalated into a thunderclap, and he became lethargic and vertiginous. His girlfriend called an ambulance to take him to the emergency room in his local rural hospital, which lacked a CT or MRI scanner.

The ER physician, Dr. Jane Benamy, worried about brain bleeding, called neurologist Dr. Roy Jones at the regional referral hospital (a few hundred miles away) requesting that Torrence be transferred. Jones refused, reassuring Benamy that the case sounded like “benign positional vertigo.” Benamy worried, but had no recourse. She sent Torrence home with medications for vertigo and headache.

The next morning, Benamy reevaluated Torrence, and he was markedly worse, with more headache and vertigo, now accompanied by vomiting and photophobia (bright lights hurt his eyes). She called neurologist Jones again, who again refused the request for transfer. Completely frustrated, she hospitalized Torrence for intravenous pain medications and close observation.

The next day, the patient was even worse. Literally begging, Benamy found another physician (an internist named Soloway) at Regional Medical Center to accept the transfer, and Torrence was sent there by air ambulance. The CT scan at Regional was read as unrevealing (in retrospect, a subtle but crucial abnormality was overlooked), and Soloway managed Torrence’s symptoms with more pain medicines and sedation. Overnight, however, the patient deteriorated even further—“awake, moaning, yelling,” according to the nursing notes—and needed to be physically restrained. Soloway called the neurologist, Dr. Jones, at home, who told him that he “was familiar with the case and … the non-focal neurological exam and the normal CT scan made urgent clinical problems unlikely.” He went on to say that “he would evaluate the patient the next morning.”

But by the next morning, Torrence was dead. An autopsy revealed that the head trauma had torn a small cerebellar artery, which led to a cerebellar stroke (an area of the brain poorly imaged by CT scan). Ultimately, the stroke caused enough swelling to trigger brainstem herniation—extrusion of the brain through one of the holes in the base of the skull, like toothpaste squeezing through a tube. This cascade of falling dominoes could have been stopped at any stage, but that would have required the expert neurologist to see the patient, recognize the signs of the cerebellar artery dissection, take a closer look at the CT scan, and order an MRI.1

Cases like this one—specifically Dr. Jones’s refusal to personally evaluate a challenging and rapidly deteriorating patient when asked repeatedly by concerned colleagues to do so—demonstrate the tension between the “no-fault” stance embraced by the patient safety field and the importance of establishing and enforcing standards. That such cases occur should not surprise anyone. Despite years of training, doctors are as vulnerable as anyone to all the maladies that can beset professionals in high-demand, rapidly changing professions: not keeping up, drug and alcohol abuse, depression, burnout, or just failing to care enough.

But how can we reconcile the need for accountability with our desire to abandon our traditional “blame and shame” approach and embrace a new focus on system safety? As Dr. Lucian Leape, the Harvard surgeon and father of the modern patient safety movement, once told me:

There is no accountability. When we identify doctors who harm patients, we need to try to be compassionate and help them. But in the end, if they are a danger to patients, they shouldn’t be caring for them. A fundamental principle has to be the development and then the enforcement of procedures and standards. We can’t make real progress without them. When a doctor doesn’t follow them, something has to happen. Today, nothing does, and you have a vicious cycle in which people have no real incentive to follow the rules because they know there are no consequences if they don’t. So there are bad doctors and bad nurses, but the fact that we tolerate them is just another systems problem.1

One of the definitions of a profession is that it is self-policing: it sets its own standards and enforces them with its members (“peer review”). Despite this responsibility, it is undeniable that doctors and hospitals tend to protect their own, sometimes at the expense of patients. Hospital credentials committees, which certify and periodically recertify individual doctors, rarely limit a provider’s privileges, even when there is stark evidence of failure to meet a reasonable standard of care. If alcohol or drug abuse is the problem, a physician may be ordered to enter a “diversion” program, a noble idea, but one that sometimes errs on the side of protecting the interests of the dangerous provider over an unwitting public. A recent survey found that 70% of physicians believe it is their professional responsibility to report an impaired or incompetent colleague. However, of physicians familiar with just such a colleague, one-third admitted that they failed to report him or her to a relevant authority.2

Why has healthcare not lived up to its ethical mandate to self-regulate? One reason is that it is difficult to sanction one’s own peers, especially when the evidence of substandard practice is anecdotal and sometimes concerns issues of personality (i.e., the disruptive physician [an issue I’ll return to below], or the physician who appears to be insufficiently responsive) rather than “hard outcomes.” A second issue is more practical: given the length of time that it takes to train physicians, credentials committees and licensing bodies are understandably reluctant to remove a physician’s privileges after the community has invested so much money and effort in training.

A final reason is that physicians tend not to be strong organizational managers. Unlike fields like law and business, in which conflict and competition are commonplace, physicians are generally not accustomed to confronting colleagues, let alone managing the regulatory and legal consequences of such confrontations. This final point is important: because litigation often follows any challenges to a physician’s clinical competence (and credentials committee members are only partially shielded from lawsuits), many physicians understandably will do backflips to avoid confrontation.

Unfortunately, the evidence that there are bad apples—and that they are not dealt with effectively—is reasonably strong. For example, from 1990 to 2002, just 5% of U.S. doctors were involved in 54% of the payouts reported to the National Practitioner Data Bank, the confidential log of malpractice cases maintained by the federal government. Of the 35,000 doctors with two or more payouts, only 8% were disciplined by state boards. And among the 2774 doctors who had made payments in five or more cases, only 463 (just one out of six) had been disciplined. One Pennsylvania doctor paid a whopping 24 claims totaling $8 million between 1993 and 2001, including a wrong-site surgery and a retained instrument case, yet had been neither stripped of his clinical credentials nor disciplined by the state licensing board.3

Of course, in this group of oft-sued doctors4 are some very busy obstetricians and neurosurgeons who take on tough cases (probably accompanied by poor bedside manner—there is a striking correlation between the number of patient complaints about a physician’s personal style and the probability of lawsuits5). But this group undoubtedly also includes some very dangerous doctors. We simply must find better ways to measure whether doctors are meeting the relevant professional standards—the increasing computerization of practice should help by making it easier to tell whether doctors are practicing high-quality, evidence-based medicine. Moreover, efforts at remediation (and discipline, if necessary) must begin early: one study found that evidence of unprofessional behavior in medical school was a powerful predictor of subsequent disciplinary action by medical boards, often decades later.6

While the above discussion has emphasized the quality of physician care, similar issues arise with other health professionals. In these other fields, however, there has been a stronger tradition of accountability, in part because nurses often work for institutions such as hospitals (and therefore can be more easily fired or disciplined) and because they have less power. But these judgments can also be arbitrary and ineffective, and the disparity with physicians creates its own problems. The bar for competence and performance should be set high for all healthcare professionals, and the consequences of failing to meet standards should be similar.7 Nothing undermines an institution’s claim to be committed to safety more than for frontline workers to see that there is one set of standards for nurses and a wholly different one for physicians.

In this regard, a major change over the past few years has been the development of critical safety rules and standards (see also Chapter 15). Whereas concerns about professional performance in the past largely centered on clinical competence (i.e., frequent diagnostic errors, poor surgical skill), they increasingly relate to failure to adhere to standards and regulations. For example, what should be done about the physician who chooses not to perform a “time out” prior to surgery (Chapter 5)? Or the nurse who habitually fails to clean her hands before patient contact (Chapter 10)? In the end, healthcare organizations must find the strength to enforce these rules and standards, recognizing that there is no conflict between this tough love stance and the “systems approach” to patient safety. As safety expert James Reason says of habitual rule benders:

Seeing them get away with it on a daily basis does little for morale or for the credibility of the disciplinary system. Watching them getting their “come-uppance” is not only satisfying, it also serves to reinforce where the boundaries of acceptable behavior lie … Justice works two ways. Severe sanctions for the few can protect the innocence of the many.8

Moreover, there are cases of such egregious deviations from professional norms that the perpetrators must be held accountable in the name of justice and patient protection. Take the case of the Saskatchewan anesthetist convicted of criminal negligence for leaving the operating room to make a phone call (after disconnecting the ventilator alarms), leading to permanent brain injury in a 17-year-old patient,9 or the Boston surgeon who left his patient anesthetized on the table with a gaping incision in his back to go cash a check at his local bank.10 And even these cases pale in comparison to those of psychopathic serial killers such as Dr. Michael Swango and Dr. Harold Shipman.11,12 These cases cry out for justice and accountability, but they are overwhelmingly the exception, which is what makes the issue of exercising appropriate accountability so vexing. The more pressing issue is how to create and enforce a system of accountability in more common situations, such as when caregivers’ behavior gets in the way of good patient care.

Although TV physicians of yesteryear were usually kind, grandfatherly types (exemplified most famously by Robert Young as Marcus Welby, MD), today’s version is Dr. Gregory House: a brilliant diagnostician who is virtually impossible to work with. This stereotype, though both dramatic and amusing, can obscure the fact that disruptive and unprofessional behavior by clinicians is relatively common and can compromise patient safety.

While only 2% to 4% of caregivers regularly engage in disruptive behavior, those who do cause substantial problems.13 In a 2008 survey of nearly 5000 nurses and physicians, 77% reported witnessing physicians engage in disruptive behavior (most commonly verbal abuse of a staff member), and 65% reported seeing disruptive behavior by nurses.14

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