Dr Alwin Tan, GAICD, MBBS, FRACS, EMBA (Melbourne Business School)

Senior Surgeon | Governance Leader | HealthTech Co-founder | Founder of Institute for Systems Integrity (ISI) |Harvard Medical School — AI in Healthcare| University of Oxford — Sustainable Enterprise | Bastas Academy for Healthcare Leadership - Triple Scholar

INSTITUTE FOR SYSTEMS INTEGRITY

The Accountability Transfer™: How organisations create the conditions for failure, blame the person closest to the patient — and leave the decisions above them largely untouched.

A nurse is short-staffed.

Again.

The ward is full.

Again.

The patients are more complex.

The phones keep ringing.

A family needs an answer.

A discharge is waiting.

A medication is due.

Another patient deteriorates.

Documentation is incomplete.

Someone has called in sick.

There is no replacement.

The organisation needs the shift covered.

The targets still apply.

The policies still apply.

The documentation requirements still apply.

The safety standards still apply.

Everything still applies.

Except the resources required to do all of it safely.

So the nurse does what healthcare workers have done for generations.

They compensate.

They move faster.

They skip the break.

They prioritise.

They improvise.

They stay late.

They carry more.

They give 110%.

Then 120%.

Then 150%.

And somehow the shift survives.

The patients are cared for.

The dashboard remains green.

Management sees no catastrophe.

So tomorrow:

the organisation asks for 150% again.

Until one day something is missed.

And suddenly the language changes.

THE SYSTEM DEMANDED 150%.

BUT WHEN SOMETHING WENT WRONG, ACCOUNTABILITY BECAME 100% PERSONAL.

"Why didn't the nurse notice?"

"Why didn't the doctor escalate?"

"Why wasn't the medication given?"

"Why wasn't the documentation completed?"

"Why wasn't the policy followed?"

"Why didn't they ask for help?"

"Why didn't they manage their workload?"

These may all be legitimate questions.

But there is another set of questions.

Who designed the workload?

Who approved the staffing model?

Who knew the vacancies existed?

Who accepted the overtime?

Who knew people were missing breaks?

Who knew the workaround had become routine?

Who saw the incident reports?

Who received the workforce data?

Who watched experienced staff leave?

Who decided the service could continue anyway?

And perhaps most importantly:

WHO DECIDED THAT 150% HUMAN EFFORT WAS AN ACCEPTABLE SUBSTITUTE FOR 100% SYSTEM CAPACITY?

Those questions tend to travel further up the organisation.

And sometimes they become harder to answer.

THE FRONTLINE LEAVES FINGERPRINTS.

THE SYSTEM LEAVES SPREADSHEETS.

That difference matters.

When a nurse makes a medication error, there is a person.

A name.

A time.

A patient.

A medication.

A signature.

A documented action.

It is concrete.

Visible.

Investigable.

Now consider chronic understaffing.

Where is its signature?

Perhaps in a workforce plan.

A budget.

A vacancy report.

An establishment figure.

A recruitment freeze.

A business case that was not approved.

A roster repeatedly operating below preferred capacity.

A decision made months earlier.

A risk accepted in a meeting far away from the patient.

These influences are distributed across time, departments and levels of authority.

Nobody necessarily touches the patient.

Nobody necessarily administers the medication.

Nobody necessarily makes the final clinical decision.

But that does not mean those decisions are causally irrelevant.

James Reason's seminal work distinguished between the person approach to error — focusing on the individual who made the mistake — and the systems approach, which examines the conditions under which people work and the upstream organisational factors that shape failure (Reason, 2000).

Reason's point remains deeply relevant to healthcare.

Human beings are fallible.

The governance question is therefore not simply:

“Who made the mistake?”

It is:

“WHAT CONDITIONS MADE THIS MISTAKE MORE LIKELY — AND WHO HAD THE AUTHORITY TO CHANGE THEM?”

THIS IS THE ACCOUNTABILITY TRANSFER™

We propose a phenomenon we call:

THE ACCOUNTABILITY TRANSFER™

The process by which risk is created across a system, tolerated through organisational decisions and absorbed through frontline compensation — but responsibility becomes concentrated on the person closest to the adverse outcome once that risk finally materialises.

It can look like this:

Demand exceeds sustainable capacity

↓

Frontline staff compensate

↓

The outcome is protected

↓

Leadership sees continued performance

↓

Exceptional effort becomes normalised

↓

System capacity remains unchanged

↓

Human margin progressively narrows

↓

Error or omission occurs

↓

Patient experiences harm

↓

Investigation begins

↓

Attention concentrates on the person closest to the event

↓

“Why didn't they…?”

↓

Individual counselling / retraining / remediation / discipline

↓

Underlying operating conditions remain substantially unchanged

↓

THE NEXT PERSON RETURNS TO THE SAME SYSTEM

If that happens, the organisation may have investigated the event.

But has it investigated the failure?

THE 150% FAILURE CASCADE™

This is the uncomfortable sequel to organisational heroism.

At 150%, people can look extraordinary.

They keep the ward functioning.

Keep the theatre moving.

Keep the clinic running.

Keep the service delivering.

But human beings do not acquire infinite cognitive capacity simply because an organisation requires more from them.

Attention is finite.

Working memory is finite.

Physical capacity is finite.

Time is finite.

The ability to continuously prioritise competing risks is finite.

This does not mean there is a scientifically defined “150% threshold” at which people suddenly make errors.

There isn't.

The 150% is deliberately metaphorical.

But the underlying relationship matters.

Research consistently links staffing and workload conditions with patient outcomes. A systematic review of longitudinal studies found that the evidence supports an overall beneficial effect of higher registered-nurse staffing on preventing patient death, while also noting important limitations and heterogeneity in the underlying evidence (Dall'Ora et al., 2022).

The governance implication is simple:

HUMAN PERFORMANCE CANNOT BE SEPARATED FROM THE CONDITIONS IN WHICH HUMANS ARE ASKED TO PERFORM.

Yet sometimes our accountability systems behave as though it can.

WE CELEBRATE THE COMPENSATION — UNTIL THE COMPENSATION FAILS

Yesterday the nurse stayed late.

Committed.

Yesterday the doctor saw another patient.

Dedicated.

Yesterday the manager fixed another broken process.

Reliable.

Yesterday the team worked short and still met the target.

Resilient.

Today someone missed something.

And suddenly:

Performance concern.

That transition deserves scrutiny.

Because organisations can unintentionally create a dangerous bargain:

WHEN YOUR EXTRAORDINARY EFFORT SAVES US, IT BELONGS TO THE ORGANISATION.

WHEN YOUR HUMAN LIMITS FAIL US, THE FAILURE BELONGS TO YOU.

That is not balanced accountability.

It is accountability travelling downhill.

THE PERSON AT THE BEDSIDE IS EASIER TO SEE THAN THE DECISION MADE SIX MONTHS EARLIER

This may be one reason accountability concentrates at the frontline.

Proximity creates visibility.

The nurse administered the medication.

The doctor made the decision.

The pharmacist dispensed the drug.

The technician performed the test.

Their actions sit immediately beside the outcome.

Executive and organisational decisions are different.

They may shape:

staffing;

workload;

technology;

training;

workflow;

rostering;

resource allocation;

performance targets;

and escalation pathways.

But their effects can be delayed and distributed.

A staffing decision made months ago may influence hundreds of clinical encounters.

No single patient may be attached to the spreadsheet on which that decision was made.

Until something goes wrong.

Then the patient's name becomes attached to the clinician who happened to be standing at the sharp end when accumulated risk finally became harm.

PROXIMITY TO HARM SHOULD NOT AUTOMATICALLY MEAN OWNERSHIP OF ALL THE CAUSES OF HARM.

AND THEN HINDSIGHT ARRIVES

After the event, something else changes.

Everyone knows the ending.

The deterioration now looks obvious.

The missing documentation looks significant.

The unanswered phone call matters.

The alternative decision seems clearer.

The warning signal appears brighter.

We ask:

"How could they possibly have missed that?"

But the person making the decision did not know the ending.

Hugh and Dekker's review describes how hindsight and outcome bias can distort retrospective judgments of medical negligence: once an adverse outcome is known, retrospective observers may perceive the preceding risk and decisions differently (Hugh and Dekker, 2009).

That creates another governance danger.

AFTER THE PATIENT IS HARMED, EVERYONE CAN SEE THE DECISION THE FRONTLINE “SHOULD” HAVE MADE.

THE HARDER QUESTION IS WHETHER IT WAS EQUALLY OBVIOUS BEFORE ANYONE KNEW THE OUTCOME.

A fair investigation has to reconstruct the world as it appeared before the harm.

What information was available?

What competing demands existed?

What staffing was present?

What interruptions occurred?

What other patients required attention?

What signals were ambiguous?

What support was realistically accessible?

What had become normal in that environment?

Without that reconstruction, hindsight can turn complexity into apparent incompetence.

“THEY SHOULD HAVE ASKED FOR HELP.”

This sentence deserves particular attention.

What if they did?

Yesterday.

Last week.

For six months.

Through incident reports.

Roster concerns.

Vacancy reports.

Emails.

Escalations.

Staff surveys.

Overtime.

Sick leave.

Turnover.

Repeated workarounds.

Near misses.

And nothing materially changed?

At what point does:

“Why didn't they escalate?”

need to become:

“WHAT HAPPENED TO ALL THE PREVIOUS ESCALATIONS?”

A reporting system is not evidence of governance if the signal travels upward and nothing meaningful travels back down.

RETRAINING THE PERSON IS EASY

Something goes wrong.

The organisation responds.

Mandatory education.

Competency review.

Policy reminder.

Reflective practice.

Performance management.

Another checklist.

Another module.

Another signature confirming that the employee understands the procedure.

Sometimes these responses are entirely appropriate.

But AHRQ's systems-focused guidance warns that focusing solely on individual performance does not prevent another person encountering the same conditions and making the same error. Event analysis should examine the system factors that facilitated the event, while still maintaining appropriate standards of individual accountability.

So before prescribing another training module, perhaps organisations should ask:

Was lack of knowledge actually the problem?

If a nurse knew exactly what should have been done but had ten competing demands simultaneously, more education may not create more time.

If a doctor understood the escalation policy but could not access the required support, another policy reminder may not create support.

If everyone understands the procedure but nobody can reliably execute it under the actual workload:

YOU MAY NOT HAVE A TRAINING PROBLEM.

YOU MAY HAVE DESIGNED WORK THAT CANNOT RELIABLY BE PERFORMED AS WRITTEN.

JUST CULTURE DOES NOT MEAN NOBODY IS ACCOUNTABLE

This argument can easily be misunderstood.

Systems thinking must never become:

“Nobody is responsible for anything.”

Individuals remain accountable for their choices.

Deliberate misconduct matters.

Recklessness matters.

Dishonesty matters.

Knowingly ignoring critical safety requirements matters.

Repeated unsafe behaviour despite reasonable conditions, training and support matters.

A Just Culture is not a no-accountability culture. AHRQ explicitly describes the need to distinguish human error and system contribution from reckless behaviour, while maintaining appropriate individual accountability.

And research on accountability in patient safety argues that treating “individual” and “system” responsibility as opposing alternatives is itself too simplistic; individuals and systems are interdependent (Aveling, Parker and Dixon-Woods, 2016).

So the question should never be:

PERSON OR SYSTEM?

It should be:

DID WE INVESTIGATE BOTH WITH THE SAME RIGOUR?

Because:

SYSTEM ACCOUNTABILITY MUST NEVER BECOME AN EXCUSE FOR INDIVIDUAL RECKLESSNESS.

BUT INDIVIDUAL ACCOUNTABILITY MUST NEVER BECOME AN EXCUSE FOR SYSTEM NEGLIGENCE.

ACCOUNTABILITY SHOULD FOLLOW AUTHORITY AS WELL AS PROXIMITY

This may be the most important governance principle in this paper.

The person closest to the harm is not necessarily the person with the greatest power to prevent its recurrence.

A frontline worker may control the next five minutes.

A manager may control tomorrow's roster.

An executive may control workforce establishment.

A board may oversee organisational risk appetite, workforce strategy and safety governance.

Different people therefore carry different forms of responsibility.

But our investigations can disproportionately examine the five minutes.

Because the five minutes are visible.

GOOD GOVERNANCE MUST ALSO INVESTIGATE THE FIVE MONTHS THAT CREATED THEM.

Who knew?

When did they know?

What signals existed?

What decisions were made?

What risks were accepted?

What resources were withheld?

What warnings became normal?

What corrective action was deferred?

What did executives see?

What did the board see?

And crucially:

What should they reasonably have known?

That is accountability moving upward as well as downward.

THE EXECUTIVE FLOOR SHOULD NOT BE OUTSIDE THE INCIDENT TIMELINE

Imagine an investigation timeline.

08:03 — medication due.

08:07 — competing clinical deterioration.

08:12 — nurse interrupted.

08:18 — medication delayed.

08:31 — patient deteriorates.

Excellent.

Now extend the timeline.

Three months earlier — vacancy remains unfilled.

Ten weeks earlier — workload concern raised.

Eight weeks earlier — overtime increases.

Six weeks earlier — near miss reported.

Five weeks earlier — experienced employee resigns.

Four weeks earlier — replacement delayed.

Three weeks earlier — staff survey identifies workload pressure.

Two weeks earlier — another workaround introduced.

Yesterday — shift again operates below preferred staffing.

Today — adverse event.

Suddenly the story looks different.

THE INCIDENT DID NOT NECESSARILY BEGIN AT 08:03.

IT MAY HAVE BEEN BUILDING FOR MONTHS.

And some of the most consequential decisions may have occurred nowhere near the patient.

THE SYSTEM CANNOT HAVE IT BOTH WAYS

An organisation cannot repeatedly say:

"We need everyone to stretch."

"We need flexibility."

"We need resilience."

"We need more with less."

"Just get through this period."

"Everyone needs to step up."

and then, when predictable human limits finally appear, behave as though the operating conditions had nothing to do with the outcome.

YOU CANNOT NORMALISE 150% PERFORMANCE AND THEN INVESTIGATE THE HUMAN BEING AS THOUGH THEY WERE OPERATING AT 50%.

Context does not remove accountability.

Context makes accountability meaningful.

THE ACCOUNTABILITY TRANSFER™ SHOULD BECOME A GOVERNANCE RED FLAG

After every serious adverse event, boards and executives should ask:

Are we investigating only the person closest to the event?

What operating conditions shaped their choices?

Were those conditions known beforehand?

Had similar concerns previously been raised?

Did successful frontline compensation hide the severity of the problem?

Who had authority to change those conditions?

What decisions did they make?

What constraints shaped those decisions?

Are corrective actions changing the system — or merely changing the person?

And one final question:

IF WE REPLACED THE PERSON TOMORROW BUT LEFT EVERYTHING ELSE UNCHANGED, HOW CONFIDENT ARE WE THAT THE SAME THING COULD NOT HAPPEN AGAIN?

If the answer is:

"Not very."

then the investigation is not finished.

THE MOST DANGEROUS ORGANISATION MAY NOT BE THE ONE WHERE PEOPLE MAKE MISTAKES

People will make mistakes.

Healthcare will never eliminate human fallibility.

The more dangerous organisation may be the one that repeatedly creates the conditions in which mistakes become more likely, relies on extraordinary people to prevent them, and then treats the eventual failure as evidence that the individual was the problem.

Because blame feels like action.

Someone has been identified.

Someone has been counselled.

Someone has been retrained.

Someone may even have been removed.

Case closed.

But AHRQ's patient-safety guidance is explicit about the underlying problem: replacing or correcting individuals without addressing system conditions can leave the opportunity for recurrence intact.

Which leaves us with an uncomfortable possibility.

SOMETIMES REMOVING THE PERSON DOES NOT REMOVE THE RISK.

IT JUST CREATES A VACANCY FOR THE NEXT PERSON WHO WILL INHERIT IT.

THE SYSTEM PUSHED THEM TO 150%.

Then the day came when human capacity was not enough.

Something was missed.

A patient was harmed.

An investigation began.

And suddenly the organisation became very interested in personal responsibility.

It should.

Patient harm deserves rigorous accountability.

But accountability that stops at the bedside is incomplete.

If the frontline worker's actions deserve scrutiny, so do the conditions under which those actions occurred.

If their judgement deserves scrutiny, so do the decisions that shaped their workload.

If their five minutes deserve reconstruction, so do leadership's preceding five months.

If the organisation asks:

“Why didn't they do better?”

governance must also ask:

“WHY DID WE REQUIRE THEM TO KEEP DOING MORE?”

Because there is something profoundly wrong with an accountability system that allows risk to travel downward while responsibility never travels back up.

The frontline should never be immune from accountability.

Neither should leadership.

Neither should executives.

Neither should boards.

ACCOUNTABILITY SHOULD FOLLOW THE ENTIRE CAUSAL CHAIN — NOT STOP AT THE FIRST PERSON WITH A NAME BADGE.

And perhaps that is the real test of a Just Culture.

Not whether someone was held accountable.

But whether everyone who materially shaped the conditions of the outcome was willing to stand inside the same accountability frame.

Because when a system repeatedly demands 150% and eventually receives a human mistake:

THE MISTAKE MAY BELONG TO AN INDIVIDUAL.

THE CONDITIONS THAT MADE IT MORE LIKELY MAY BELONG TO THE ORGANISATION.

A SYSTEM WITH INTEGRITY MUST BE BRAVE ENOUGH TO INVESTIGATE BOTH.

References

Aveling, E-L., Parker, M. and Dixon-Woods, M. (2016) ‘What is the role of individual accountability in patient safety? A multi-site ethnographic study’, Sociology of Health & Illness, 38(2), pp. 216–232. doi:10.1111/1467-9566.12370.

Dall'Ora, C., Saville, C., Rubbo, B., Turner, L., Jones, J. and Griffiths, P. (2022) ‘Nurse staffing levels and patient outcomes: A systematic review of longitudinal studies’, International Journal of Nursing Studies, 134, 104311. doi:10.1016/j.ijnurstu.2022.104311.

Hugh, T.B. and Dekker, S.W.A. (2009) ‘Hindsight bias and outcome bias in the social construction of medical negligence: a review’, Journal of Law and Medicine, 16(5), pp. 846–857.

Reason, J. (2000) ‘Human error: models and management’, BMJ, 320(7237), pp. 768–770. doi:10.1136/bmj.320.7237.768.

Agency for Healthcare Research and Quality (AHRQ) (n.d.) System-Focused Event Investigation and Analysis Guide. Rockville, MD: Agency for Healthcare Research and Quality.

Agency for Healthcare Research and Quality (AHRQ) (n.d.) Systems Approach. Patient Safety Network. Rockville, MD: Agency for Healthcare Research and Quality.

Agency for Healthcare Research and Quality (AHRQ) (n.d.) Culture of Safety. Patient Safety Network. Rockville, MD: Agency for Healthcare Research and Quality.