Balancing Systems and Individual Accountability in a Safety Culture

Back to the case• The RCA revealed:• As the nurse approached patient’s bedside, he cameunder a barrage of expletives from Surgeon X aboutgetting the #@*&%! blood in.• Nurse asserted, “I tried once to state I was followingprocedure but felt pressured to do as ordered.”• Another team member—an RN—recognized the high-risksituation but reflected, “I just didn’t speak up.”Hickson GB et al. Balancing Systems and Individual Accountability in a Safety Culture. In S Berman (Ed).From Front Office to Front Line: Essential Issues for Health Care Leaders, 2nd edn. Chicago: JCRI, in press.35NPSF Professional Learning Series