When errors occur or something goes wrong in a health care organization, the first question people often ask is, “Whose fault is it?” For instance, if medications are late, it’s the pharmacy’s fault; if a patient falls, the nursing staff and physical therapists are blamed.
In an organization with a culture of blame, it can lead to a hindrance in learning, improvement, and development. This can deter error reporting and result in compromised patient safety. When people worry about being punished, they are more likely to cover up mistakes, deny responsibilities, or conceal their real concerns—these behaviors limit organizations’ ability to identify and address systemic issues.
It is important to acknowledge that even with the most conscientious efforts, physicians and other health care workers will “inevitably make mistakes by omission, commission, or simply as a result of human nature and imperfections of work environments” (Eng & Schweikart, 2020). Recognizing this reality requires a shift from blame to accountability, where errors become opportunities to learn, accept, and promote safer patient care rather than occasions for shame or punishment.
Who is Responsible? Incorporating Accountability in Teams
In the article, “How Leaders Create a Culture of Accountability in Health Care”, the authors highlight the responsibility leaders have to set team culture and create learning environments. The article highlights having a “cup of coffee” conversation after a moderate, single incident that is “a private, informal conversation where the aim is not to pass a verdict, but rather to raise awareness of an issue and gain a better understanding from their perspective” (James, 2019). For more severe incidents, a “DESC” discussion is recommended. This involves:
- Describe: Describe the behavior or performance issue as objectively as possible. Avoid drawing conclusions.
- Explain: Explain the results of their actions, including the impact on the team and the broader organization.
- Specify: Specify the desired change and work together to find solutions. This is an opportunity to help build personal accountability.
- Commitment: Ensure mutual commitment and understanding of the action plan. Express the consequences (both positive and negative) of future results.
Balance of Accountability
In order to promote a safe, thoughtful and responsible culture, accountability is a required action. However, finding a balance between blame and faultlessness is needed for a true environment of growth and learning (Dekker, 2016).
That is the ultimate goal of a just culture–a specific environment that prioritizes shared accountability so employees can feel open to report errors without fear of unjust consequences. With shared accountability in an organizational lens, organizations take on the responsibility of the systems they create, as well as a fair and just response to their employees' errors. This culture of accountability allows for a quality learning environment where the organization can focus on how to improve, instead of who to blame.
“We know that creating a safe and transparent environment encourages reporting of mistakes and hazards and ultimately improves the care we provide to our patients,” says Brigham and Women's Faulkner Hospital Chief Medical Officer Dr. Peggy Duggan. (BWFH, n.d.).
It is important to note, however, that building a culture within an organization that allows people to speak up without previously held fears is something that takes time. It is crucial to build this culture by training leaders on how to take a different approach to accountability and foster a just culture in their everyday conversations.
Actions You Can Take
- Ask WHAT is responsible, not WHO is responsible. Instead of investigating who is responsible for a mistake, ask what is responsible for prioritizing safety over criticism.
- Shared Accountability. Focus on system improvements instead of individual wrongdoings.
- Safe Reporting. Employees are actively encouraged to report errors in the workplace without fear of unjust punishment to ensure the safety of patients.
- Learning Environment. Focus on framing errors as a learning opportunity to prevent future mistakes.
References
American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/home
Boysen P. G., 2nd (2013). Just culture: a foundation for balanced accountability and patient safety. Ochsner journal, 13(3), 400–406. https://pmc.ncbi.nlm.nih.gov/articles/PMC3776518/#i1524-5012-13-3-400-b01
Brigham and Women’s Faulkner Hospital. (n.d.). What is just culture? Changing the way we think about errors to improve patient safety and staff satisfaction. https://www.brighamandwomensfaulkner.org/about-bwfh/news/what-is-just-culture-changing-the-way-we-think-about-errors-to-improve-patient-safety-and-staff-satisfaction
Dekker, S. (2016). Just culture: Balancing safety and accountability. https://scholar.google.com/scholar_lookup?title=Just%20Culture:%20Balancing%20Safety%20and%20Accountability&author=S%20Dekker&publication_year=2008&
Eng, D. M., & Schweikart, S. J. (2020). Why Accountability Sharing in Health Care Organizational Cultures Means Patients Are Probably Safer. AMA Journal of Ethics, 22(9), 779–783. https://doi.org/10.1001/amajethics.2020.779
James, T. A. (2019, August 15). How leaders create a culture of accountability in health care. Harvard Medical School. https://postgraduateeducation.hms.harvard.edu/trends-medicine/how-leaders-create-culture-accountability-health-care
Paul, M. (2016, February 27). Moving from Blame to Accountability. The Systems Thinker. https://thesystemsthinker.com/moving-from-blame-to-accountability/