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

  • Elizabeth A. Duthie


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.


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


  1. 1.
    Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer healthcare system. Washington: National Academy Press; 2000.Google Scholar
  2. 2.
    Dekker S. Patient safety: a human factors approach. Boca Raton: CRC Press Taylor & Francis Group; 2011.CrossRefGoogle Scholar
  3. 3.
    Amalberti R, Auroy Y, Berwick DM, Barach P. Five system barriers to achieving ultra-safe health care. Ann Intern Med. 2005;142(9):756–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Pate B, Stajer R. The diagnosis and treatment of blame. J Healthc Qual. 2001;23(1):4–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Dekker S. Second victim: error, guilt, trauma and resilience. Boca Raton: CRC Press Taylor & Francis Group; 2013.CrossRefGoogle Scholar
  6. 6.
    Walton M. Creating a “no blame” culture: have we got the balance right? Qual Saf Health Care. 2004;13:163–4.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Goldman D. System failure versus personal accountability: the case for clean hands. N Engl J Med. 2006;355:121–3.CrossRefGoogle Scholar
  8. 8.
    Wachter RM. Personal accountability in healthcare: searching for the right balance. BMJ Qual Saf. 2013;2:176–80.CrossRefGoogle Scholar
  9. 9.
    Wachter RM, Pronovost PJ. Balancing ‘no blame’ with accountability in patient safety. N Engl J Med. 2009;361:1401–6.CrossRefPubMedGoogle Scholar
  10. 10.
    McTiernan P, Wachter RM, Meyer GS, Gandhi TK. Patient safety is not elective: a debate at the NPSF Patient Safety Congress. BMJ Qual Saf. 2015;24(2):162–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Reason J. Human error. New York: Cambridge University Press; 1990.CrossRefGoogle Scholar
  12. 12.
    The Joint Commission on Accreditation of Healthcare Organizations. What every healthcare organization should know about sentinel events. Oakbrook: Joint Commission Resources; 2005.Google Scholar
  13. 13.
    Woods DD, Dekker S, Cook R, Johannesen L, Sarter N. Behind human error. Burlington: Ashgate; 2010.Google Scholar
  14. 14.
    Dekker S. The field guide to understanding human error. Burlington: Ashgate; 2006.Google Scholar
  15. 15.
    Gentner D, Stevens A, editors. Mental models. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1983.Google Scholar
  16. 16.
    Moray N. Error reduction as a systems problem. In: Bogner MS, editor. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1994. p. 67–92.Google Scholar
  17. 17.
    Helmreich RL, Schaefer HG. Team performance in the operating room. In: Bogner MS, editor. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1994. p. 225–54.Google Scholar
  18. 18.
    Cook RI, Woods DD. Operating at the sharp end: the complexity of human error. In: Bogner MS, editor. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1994. p. 255–310.Google Scholar
  19. 19.
    Espin S, Lingard L, Baker GR, Regehr G. Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. Qual Saf Health Care. 2006;15:165–70.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Barach P. The end of the beginning. J Legal Med. 2003;24:7–27.Google Scholar
  21. 21.
    Gaba DM. Human error in dynamic medical domains. In: Bogner MS, editor. Human error in medicine. Hillsdale: Lawrence Erlbaum Associates, Inc.; 1994. p. 197–224.Google Scholar
  22. 22.
    Dekker SW, Leveson NG. The systems approach to medicine: controversy and misconceptions. BMJ Qual Saf. 2015;24(1):7–9.CrossRefPubMedGoogle Scholar
  23. 23.
    Dekker S. The field guide to human error investigations. Burlington: Ashgate; 2002.Google Scholar
  24. 24.
    Apostolakis G, Barach P. Lessons learned from nuclear power. In: Hatlie M, Tavill K, editors. Patient safety, international textbook. New York: Aspen Publications; 2003. p. 205–25.Google Scholar
  25. 25.
    Cassin B, Barach P. Making sense of root cause analysis investigations of surgery-related adverse events. Surg Clin N Am. 2012, 1–15. doi: 10.1016/j.suc.2011.12.008.
  26. 26.
    Nicolini D, Waring J, Mengis J. Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the gap. Soc Sci Med. 2011;73:217–25.CrossRefPubMedGoogle Scholar
  27. 27.
    Reason J. Managing the risks of organizational accidents. Burlington: Ashgate; 1997.Google Scholar
  28. 28.
    Reason J. The human contribution: unsafe acts, accidents and heroic recoveries. Burlington: Ashgate; 2008.Google Scholar
  29. 29.
    Dekker S. Just culture: balancing safety & accountability. Burlington: Ashgate; 2007.Google Scholar
  30. 30.
    Duhigg D. The power of habit. New York: Random House; 2012.Google Scholar
  31. 31.
    Vohra P, Daugherty C, Mohr J, Wen M, Barach P. Housestaff and medical student attitudes towards adverse medical events. JCAHO J Qual Saf. 2007;33:467–76.Google Scholar
  32. 32.
    Cassin B, Barach P. Balancing clinical team perceptions of the workplace: applying ‘work domain analysis’ to pediatric cardiac care. Prog Pediatr Cardiol. doi: 10.1016/j.ppedcard.2011.12.005.
  33. 33.
    Khaneman D. Thinking fast & slow. New York: Farrar, Straus & Giroux; 2011.Google Scholar
  34. 34.
    Vedantam S. The hidden brain: how our unconscious minds elect presidents, control markets, wage wars and save our lives. New York: Spiegel & Grau; 2010.Google Scholar
  35. 35.
    Eagleman D. Incognito: the secret lives of the brain. New York: Vintage Books; 2011.Google Scholar
  36. 36.
    Klein G. Sources of power: how people make decisions. 2nd ed. Cambridge: The MIT Press; 1999.Google Scholar
  37. 37.
    Marx D. Whack a mole: the price we pay for expecting perfection. Plano Texas: By Your Side Studios; 2009.Google Scholar
  38. 38.
    Southwick F. Who was caring for Mary? Ann Intern Med. 1993;118:146–8.CrossRefPubMedGoogle Scholar
  39. 39.
    Southwick F, Spear S. “Who was caring for Mary?” revisited: a call for all academic physicians caring for patients to focus on systems and quality improvement. Acad Med. 2009;84:1648–50.CrossRefPubMedGoogle Scholar
  40. 40.
    Leonard MW, Frankel A. The path to safe and reliable healthcare. Patient Educ Couns. 2010;80:288–92.CrossRefPubMedGoogle Scholar
  41. 41.
    Carthey J, de Leval MR, Reason JT. Institutional resilience in healthcare systems. Qual Healthcare. 2001;10:29–32.CrossRefGoogle Scholar
  42. 42.
    Dorner D. The logic of failure: recognizing and avoiding error in complex situations. Cambridge: Basic Books; 1996.Google Scholar
  43. 43.
    Bognar A, Barach P, Johnson J, Duncan R, Woods D, Holl J, Birnbach D, Bacha E. Errors and the burden of errors: attitudes, perceptions and the culture of safety in pediatric cardiac surgical teams. Ann Thorac Surg. 2008;4:1374–81.Google Scholar
  44. 44.
    Carroll J, Rudolph J, Hatakenaka S. Lessons learned from non-medical industries: root cause analysis as culture change at a chemical plant. Qual Saf Health Care. 2002;11(3):266–9.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    National Patient Safety Foundation. RCA2 improving root cause analyses and actions to prevent harm. Accessed 20 June 2015.
  46. 46.
    Duthie EA. Recognizing and managing errors of cognitive underspecification. J Patient Saf. 2014;10(1):1–5.CrossRefPubMedGoogle Scholar
  47. 47.
    Tavris C, Aronson E. Mistakes were made (but not by me): why we justify foolish beliefs, bad decisions and hurtful acts. Orlando: Harcourt, Inc.; 2007.Google Scholar
  48. 48.
    The Joint Commission on Accreditation of Healthcare Organizations. Using aggregate root cause analysis to improve patient safety. Jt Comm J Qual Saf. 2003;29:434–9.CrossRefGoogle Scholar
  49. 49.
    Phelps G, Barach P. Why the safety and quality movement has been slow to improve care? Int J Clin Pract. 2014;68(8):932–5.Google Scholar
  50. 50.
    Percarpio KB, Watts BV, Weeks WB. The effectiveness of root cause analysis: what does the literature tell us? Jt Comm J Qual Saf. 2008;34:391–8.Google Scholar
  51. 51.
    Pham JC, Kim GR, Natterman JP, et al. ReCASTing the RCA: an improved model for performing root cause analyses. Am J Med Qual. 2010;25:186–91.CrossRefPubMedGoogle Scholar
  52. 52.
    Card AJ, Ward J, Clarkson PJ. Successful risk assessment may not always lead to successful risk control: a systematic literature review of risk control after root cause analysis. J Healthc Risk Manag. 2012;31:6–12.CrossRefPubMedGoogle Scholar
  53. 53.
    Jensen PF, Barach P. The role of human factors in the intensive care unit. Qual Saf Health Care. 2003;12(2):147–8.CrossRefPubMedCentralGoogle Scholar
  54. 54.
    Nicolini D, Waring J, Mengis J. The challenges of undertaking root cause analysis in health care: a qualitative study. J Health Serv Res Policy. 2011;16 Suppl 1:34–41.CrossRefPubMedGoogle Scholar
  55. 55.
    Vrklevski LP, McKechnie L, O’Connor N. The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best model for error investigation in mental health services. J Patient Saf. 2015. March 26, epub ahead of print.Google Scholar
  56. 56.
    Deming WE. Out of the crisis. Cambridge: MIT Center for Advanced Educational Services; 1982.Google Scholar
  57. 57.
    Kaplan HS, Fastman BR. Organization of event reporting data for sense making and system improvement. Qual Saf Health Care. 2003;12 Suppl 2:ii68–72.Google Scholar
  58. 58.
    Weick KE, Sutcliffe KM. Managing the unexpected: assuring high performance in an age of complexity. San Francisco: Jossey-Bass; 2001.Google Scholar
  59. 59.
    Sharit J, McCane L, Thevenin DM, Barach P. Examining links between sign-out reporting during shift changeovers and patient management risks. Risk Anal. 2008;28(4):983–1001.CrossRefGoogle Scholar
  60. 60.
    Satish U, Barach P, Steuffert S. Assessing and improving competency with the SMS simulation. Simul Gaming. 2001;32:156–63.CrossRefGoogle Scholar
  61. 61.
    Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz LW, Trevelyan EW. Organizational factors associated with high performance in quality and safety in academic medical centers. Acad Med. 2007;82(12):1178–86.Google Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

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

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