Chapter 12
Accountability Accountability for Patient Safety As providers, we have much to be thankful for. But to whom much is given, much is also required. One of those requirements is accountability. We are granted the right to make life-altering decisions for our patients. We are also human and fallible. Despite our best efforts and the most well-planned safeguards, mistakes will happen, and iatrogenic errors will occur. How we handle those events is a window to our character. Do we take account, or do we shift the blame? Do we self-reflect, or do we downplay and ignore? I once was called to an emergency situation that highlights the gut-wrenching reality of this dilemma. An elective operation resulted in a complication requiring the placement of a kidney drainage tube after surgery. The patient was extubated after the original surgery and then transferred to the imaging suite for the nephrostomy tube placement. During the tube placement, the very obese patient was placed on her stomach and repeatedly sedated due to complaints of severe pain. It was late afternoon. One provider and four nurses were attending to the patient, having been asked to stay after hours to perform this task. Once the procedure was complete and the patient undraped, it became obvious that the patient was cyanotic and not breathing. That’s when I was called in a panic. 149
