Television crime plots are formulaic—a body is discovered in an unexpected place, foul play is suspected, evidence is collected, and detectives work to piece together clues. Just as the episode is about to end, the final clue is discovered, revealing the perpetrator. With the criminal caught and jailed, justice ensues and public trust is restored. When a patient is harmed in healthcare, assigning blame is rarely that simple.

Each year healthcare-associated infections (HAIs) harm 1 in 31 inpatients; HAIs lead to ~99,000 preventable patient deaths in the United States annually.¹ Who do we hold accountable for these incidents of harm? Unlike on television, harm in healthcare rarely results from a single bad actor.

Healthcare organizations historically held providers accountable for cases of medical harm, but following the landmark report, “To Err Is Human: Building a Safer Health System,” focus shifted to system failures as key contributors to adverse events.Reference Kohn, Corrigan and Donaldson² Researchers noted that after years of a punitive approach to clinician errors, this “no blame” movement was widely embraced, and new systems solutions were developed to improve safe healthcare delivery.Reference Wachter and Pronovost³ Continuing research supports a just culture framework, one in which a complex landscape of systemic and individual factors contributes to patient harm with shared accountability.Reference Boysen⁴

Researcher Derick W. Brinkerhoff describes accountability as “the obligation of individuals or agencies to provide information about, and/or justification for, their actions to other actors, along with the imposition of sanctions for failure to comply and/or to engage in appropriate action.”Reference Brinkerhoff⁵ Tisné et al state, “Broadly speaking, accountability refers to the process of holding actors responsible for their actions. More specifically, it is the concept that individuals, agencies and organizations (public, private and civil society) are held responsible for executing their powers according to a certain standard (whether set mutually or not).”Reference Tisné⁶ Defining and practicing accountability is emphasized in patient safety cultures, and continuing research suggests accountability may influence the success of infection prevention strategy.

At a large tertiary-care facility, establishing an individual hand hygiene accountability program resulted in improved hand hygiene compliance and decreased device-associated standardized infections.Reference Talbot, Johnson and Fergus⁷ These findings suggest that individual accountability may support desired hand hygiene behavior in healthcare settings. At the system level, a 2010 study reported that collecting and comparing feedback of appropriate antibiotic administration for patients undergoing surgery resulted in increased compliance with this quality recommendation in US hospitals.Reference Chassin, Loeb and Schmaltz⁸ Both studies support the concept that individual and system accountability improves adherence to infection prevention processes and heightens safety.

Accountability in healthcare must be tied to clear expectations coupled with reasonable goals. Getting to zero HAIs is a sound bite, a setup for unrealistic expectations given the inexactitude of infection prevention science.Reference Edmond⁹ Current reports suggest that between 30% and 70% HAIs are potentially preventable with existing infection prevention science.Reference Dellinger^10, Reference Umscheid, Mitchell and Doshi¹¹ Appropriate goal setting ties accountability to implementation of evidence-based systems and processes grounded in practical strategies with real-world applicability. Examples include promotion, implementation, and assessment of aggressive hand hygiene programs, reliable and consistent chlorhexidine patient bathing, safety check lists, heightened daily and terminal disinfection, and antimicrobial stewardship programs. Broad, standardized execution of these safety practices is essential to infection prevention strategy.

Even when best practice is standardized, enforcement can vary within a healthcare system. At our home institution, services vary in implementing key processes such as patient chlorhexidine bathing and the use of central-line insertion checklists. Units with high safety reliability have engaged leaders and staff. Lower performing units may benefit from greater individual healthcare-worker accountability by managers and greater unit-level accountability from senior leaders. These challenges are not uncommon in healthcare. The default assumption that all shortcomings in infection prevention are due to system failures is untenable. Hospital infection prevention programs are neither staffed nor empowered for broad administrative oversight. Their role is to set collaborative standards and identify barriers to processes and outcomes. Managers, chief medical, quality, and nursing officers are responsible for accountability of both the system and the individual, with ultimate oversight from chief executive officers.

In Betrayal of Trust: The Collapse of Global Public Health, Laurie Garrett writes, “Public health is an essential trust, between government and its people, in a pursuit of health for all…” This includes “… a healthcare system that follows the primary maxim of medicine—do no harm.”Reference Garrett¹² Institutional leaders and infection preventionists play a critical role in minimizing preventable HAIs.

Infection prevention professionals best define the priorities and practices for HAI risk reduction. Institutional leaders communicate the vision, provide resources, and institutionalize and maintain changes as new practices develop.Reference Vokes, Bearman and Bazzoli¹³ Driven by the central tenet of healthcare, primum non nocere, or “do no harm,” we should relentlessly strive for zero potentially preventable infections.

Following decades of rising costs of care and reported deficits in safety and quality in the United States, organizations are increasingly called upon to publicly report data demonstrating value of care. Under this framework, healthcare systems, infection prevention programs and institutional leaders that fail to prioritize and relentlessly pursue infection prevention, by regularly assessing process and outcomes under the lens of both system and individual accountability, betray the maxim of medicine, primum non nocere. Our ethical mandate for safe and reliable care is anchored to individual and system accountability, anything less undermines the public trust.