Ms Cohen presents the oppositional choice (ie, either/or) between a "total individual responsibility" and a "total systems approach" to error reduction that we were trying to avoid in our article. Ms Cohen fails to note that the middle term not addressed in this oppositional view is "practice responsibility." Practice responsibility is not addressed at all by an individual professional responsibility approach and inadequately accounted for in the systems approach to error reduction.

We introduce "practice responsibility" as a middle term that incorporates the notions of good inherent in any self-improving practice. For the systems approach to be effective, notions of good outcomes and good means to achieve those outcomes must be derived from the practice. The systems method alone cannot adequately address this issue.

The systems approach offers a way to examine the root structural and design causes of errors taking into account human factors that contribute to error. The goal is to design a system that prevents errors due to human factors. We wholly support this approach to error reduction in the article and in the TERCAP instrument. A survey of root causes of the individual nurse's error in the TERCAP instrument is based upon a systems approach. The goal of the TERCAP instrument is to introduce analysis of both systems and practice responsibility to what has traditionally been an individual focus.

Ms Cohen seems to miss the point that practice responsibility is not the same as individual responsibility. Practice responsibility refers to the joint responsibility of all practitioners within a particular practice (eg, medicine, nursing, pharmacy) understanding and carrying out the notions of good internal to their practice on a daily basis. Practice responsibility also encompasses the education and socialization of practitioners including an ethos of practice. For example, individual practitioners could hardly be responsible for failing to get an informed consent from patients if he or she had never learned the ethics and knowledge for achieving informed consent in schools of nursing or medicine. Thus professional schools and licensing exams are accountable for teaching and testing for the practitioner's understanding of the notions of good and the science and technology involved in the practice. The site of practice is not the only site involved in creating good practice. Education, certification and licensing boards, professional societies, and scientific bodies join in the social production of practice responsibility.

A systems approach addresses errors already committed and seeks to design them out of the system. This is a good approach, and we encourage its promotion in our article. The practice responsibility approach seeks to enact the notions of good practice in the immediate situation with the practitioners available and the system in place. But it also seeks to address the ongoing education and development of the discipline. An active dialogue is needed between the individual professional responsibility, collective practice responsibility (what we call the middle term) and a systems approach to make the systems approach work, and indeed to enhance ongoing practice development and improvement. What is not needed is more oppositional argument over the merits of one approach over another singular approach.

We agree that most errors that occur can be traced to multiple system breakdowns, and/or poor system design. We also addressed the problem of the vision of individual hyper-responsibility and a culture of shame, blame, and treating the individual as a scapegoat for system failure. The State Boards of Nursing deal with only the most severe errors. The TERCAP instrument addresses practice setting systems causes and education sources of error due to lack of updating of knowledge, or inadequate basic education. Of course, one instrument cannot fully address any of these issues, but it does allow for identification of problem areas for practice settings, schools of nursing and continuing educators to address. While the systems approach has much to offer, it can solve all the problems in reducing errors. Let the dialogue flourish so that we do not get stuck in a false oppositional argument.

Patricia Benner, PhD, RN, FAAN