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As this book has emphasized, 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 most of the time. 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?1


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 ...

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