It’s My Fault: Understanding the Role of Personal Accountability, Mental Models and Systems in Managing Sentinel Events

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Abstract

Root cause analysis (RCA) is frequently employed to identify and remediate faulty systems in the wake of a sentinel event. A composite case, involving an adverse outcome in the operative arena, is presented to illuminate how personal accountability may be a barrier to discovering flawed systems. The mental models that drove the clinical decisions in the event are explained. Underlying the mental models are faulty systems which originated in the upper echelons of the organization. Personal accountability, focusing on time lines to identify problems and failing to understand the beliefs and values, acted as barriers to effectively identify and remediate flawed systems. The connection between a financial decision and a delayed intubation is presented along with strategies for successful remediation.

Keywords

Patient safety Human error Blame Accountability Mental models Systems Pre-compiled response Just culture Root cause analysis 
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Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Patient Safety Resource Center, Montefiore Medical CenterBronxUSA

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