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Patient safety and the problem of many hands
  1. Mary Dixon-Woods1,
  2. Peter J Pronovost2,3
  1. 1University of Leicester, Health Sciences, Leicester, UK
  2. 2Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, USA
  3. 3Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Professor Mary Dixon-Woods, University of Leicester, Health Sciences, 2nd Floor, Adrian Building, University of Leicester, University Road, Leicester LE1 7RH, UK; md11{at}

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Healthcare worldwide is faced with a crisis of patient safety: Notwithstanding occasional successes in relation to specific harms, safety as a system characteristic has remained elusive. We propose that one neglected reason why the safety problem has proved so stubborn is that healthcare suffers from a pathology known in the public administration literature as the problem of many hands. It is a problem that arises in contexts where multiple actors—organisations, individuals, groups—each contribute to effects seen at system level, but it remains difficult to hold any single actor responsible for these effects. Efforts by individual actors, including local quality improvement (QI) projects, may have the paradoxical effect of undermining system safety. Many challenges cannot be resolved by individual organisations, since they require whole-sector coordination and action. We call for recognition of the problem of many hands and for attention to be given to how it might most optimally be addressed in a healthcare context.


Every day, everywhere, patients are injured during the course of their care.1–3 But the puzzle of how to keep patients safe has remained stubbornly difficult to solve, despite huge optimism, effort, investment, public pressure and some occasional successes in relation to specific harms over the past 15 years or more.4 We suggest that one neglected reason for slow progress in patient safety lies in a pathology known in the public administration literature as the problem of many hands. First described by the political philosopher Dennis Thompson,5 the problem of many hands was originally developed in the context of public officials. His concern was the challenge of how responsibilities can be allocated for the decisions and policies of government when so many different officials contribute in so many ways that it is difficult to identify the causal contribution of any single individual. Summarised in the …

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  • Contributors MD-W conceived the idea for the paper and prepared a first draft. PJP made substantial contributions to revising this draft and providing additional insights. Both authors approved the final draft.

  • Funding Wellcome Trust Senior Investigator Award for Mary Dixon-Woods (WT097899).

  • Competing interests MD-W is Deputy Editor-in-Chief of BMJ Quality and Safety.

  • Provenance and peer review Not commissioned; internally peer reviewed.