A. Ten years ago, we approached patient safety as a series of system flaws; we believed that most errors were committed by good competent people doing something no more complicated than forgetting a cellphone. But in the last few years some of us in the patient safety field have begun to feel uneasy about that approach. When there are reasonably safe standards available, what do you do when people simply don’t adhere to them? At some point, it’s no longer a “systems problem.”

Q. In one of your articles, you use the example of hand hygiene to illustrate your point.

A. Hand hygiene seemed like a good place to start studying how we might find a new balance between “no blame” and accountability. We know that this particular problem can be morbid, sometimes fatal, and that the systems issues, such as the availability of sanitizing gel dispensers in hospitals, have by and large been fixed. But even with those changes in place, few health care systems have had sustainable rates of hand hygiene over 80 percent. We have not achieved the rate we would expect of ourselves, and that our patients would expect.

Most hospitals and health care organizations are starting to step up to the idea of individual accountability, but in very haphazard ways. For instance, I can lose my hospital privileges if I fail to sign a dictated discharge summary or operative note. But if I don’t clean my hands for the next 10 years, nothing will happen to me.

One of the fundamental problems of safety is embedded in this example. We operate in an environment where there are regulatory sticks and payment incentives; and in this particular example, it’s difficult to submit to an insurer if the doctor hasn’t signed off. When there’s money at stake, organizations get motivated enough to stop being too fuzzy.

Promoting safety  really doing it right  takes time and money. Ethics and professionalism are important but not enough.

Q. Do you think the safety movement has eroded trust between patients and doctors?

A. It has eroded trust in safety, but I think that was absolutely necessary. The idea from the I.O.M. report that launched this field was that there was a jumbo jet’s worth of people dying every day.

The only way we are going to fix this problem is to become much more open and transparent. That transparency will drive us to improve and allows us to educate each other.