Nancy K. Lowe Editor

I recently have been thinking a lot about leadership: leadership in nursing, leadership in academic nursing, leadership in health care, and leadership in life in general. Part of this thinking is motivated by my current role as mentor to two incredible nurse-midwife faculty members who are fellows in the 18-month, Sigma Theta Tau International/Johnson and Johnson Maternal-Child Health Leadership Academy. I learn from these midwives every time I meet with them on their journeys toward becoming leaders with accountability for their own career paths.

Another impetus for this renewed thinking about leadership is that we have a new dean in our College of Nursing. She has challenged me in new ways to consider what leadership and accountability mean. In a book she has asked us to read, The Oz Principle (Connors, Smith, & Hickman, 2004), a sentence struck me that I cannot get out of my mind: “An attitude of accountability lies at the core of any effort to improve quality, … build teams, … and get results” (p. 16). The book's authors describe behavior that is below the line of accountability as “The Blame Game” consisting of the all-too-familiar behaviors of wait-and-see, confusion/tell me what to do, it's not my job, ignore and deny, finger pointing at others, and covering your tail. These behaviors result in a work culture where “no one acknowledges the truth and people don't speak up” (p. 11), and victims reside. Behaviors above the line of accountability are see it, own it, solve it, and do it. An accountable individual or work culture acknowledges the reality of a situation (sees it), accepts responsibility for the situation (owns it), finds and implements creative solutions to problems (solves it), and exhibits the commitment and courage needed to follow through (does it). Makes sense, doesn't it? Common sense.

Health care quality, preventing errors in health care, and striving for cost-effective care have generated multiple reports, conferences, systems reforms, outcome measures, payment reforms, and technology development since the publication of To Err is Human: Building a Safer Health System (Koh, Corrigan, & Donaldson, 2000) more than a decade ago. Despite these many efforts, the authors of To Err is Human – To Delay is Deadly (Safe Patient Project, 2009) indicated that health care harms in the United States still account for more than 100,000 deaths annually or a million deaths from error in one decade. Furthermore, the authors, “give the country a failing grade on progress on select recommendations we believe necessary to create a health-care system free of preventable medical harm” (p. 1). As they noted, elements of the continuing problem of health care error include:

  • Few hospitals have adopted well-known systems to prevent medication errors and the Food and Drug Administration (FDA) rarely intervenes.
  • A national system of accountability through transparency as recommended by the Institute of Medicine (IOM) has not been created.
  • No national entity has been empowered to coordinate and track patient safety improvements.
  • Doctors and other health professionals are not expected to demonstrate competency in patient safety (p. 1).

Human factors, lapses and errors by individuals or several individuals in a system, including communication failures, have been repeatedly shown to be at the core of errors in health care. Is it possible that personal accountability, followed by team, unit, and institutional accountability are key to true improvements in safety and effectiveness in health care? Does the public have a right to a safe health care system? Or are errors that result in morbidity and mortality acceptable? Working and living above the line of accountability is not only the essence of leadership, but also illustrates individual and group behaviors that result in a high performing, that is, safe, system of care. According to The Oz Principle, accountability is “A personal choice to rise above one's circumstances and demonstrate the ownership necessary for achieving desired results [such as a safe health care system] – to See It, Own It, Solve It, and Do It” (p. 190).


  1. Top of page
  • Connors, R., Smith, T., & Hickman, C. (2004). The Oz principle: Getting results through individual and organizational accountability. London, UK: Penguin.
  • Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academy of Sciences.
  • Safe Patient Project. (2009). To err is human – To delay is deadly. Austin, TX: Consumers Union. Retrieved from pdf