ORLANDO, Fla. — Maybe the days of blame-free culture in hospitals are over, and it's long past time to start punishing doctors, regardless of their stature, for failing to practice certain safety measures.

That thought was at the heart of a scintillating debate between two of the nation's pre-eminent patient safety experts Thursday, during the opening session of the 2014 National Patient Safety Congress. It's been more than a dozen years since the patient safety movement planted its roots with the arrival of the landmark report To Err is Human. Despite the simplicity and proven effectiveness of such practices as surgical checklists and hand washing, some clinicians continue to ignore the evidence, or at least the execution.

Robert Wachter, M.D., was irked years ago when visiting a hospital where the rate of hand washing stood at 55 percent. He'd walk around the building and see gel dispensers every two feet, a poster on every wall of a smiling clinical leader cleaning his hands, or a picture on every computer screen of some nasty, pus-filled wound. His "B.S. detector" started ringing as hospital officials tried to explain away the pitiful compliance rate.

"It dawned on me that the nature of the problem was a lack of accountability," said Wachter, professor and associate chairman of the Department of Medicine at the University of California, San Francisco. "I realized at my own hospital that I would get suspended from the medical staff if I didn't take my PPD or I didn't sign my discharge summaries, but if I didn't clean my hands for the next five years then absolutely nothing would happen. That just struck me as wrong in all dimensions of the word."

Wachter argued that it's time to recalibrate the field's approach to patient safety. A blameless culture no longer makes any sense, he said, as it lacks accountability with patients. How do you explain to a family who recently lost a member to a health care-acquired infection that no one is being reprimanded for failing to wash their hands half the time?

On the flip side, fellow safety expert Gregg Meyer, M.D., chief clinical officer at Partners HealthCare, argued that bringing in the "hand-washing police" would poison the well and only serve as a distraction from the real barriers to patient safety — production pressure and a lack of systems to prevent errors. Focusing on punishment, rather than education, would undermine culture, foster fearfulness and push already stressed health care workers over the "performance anxiety curve." Plus, it just doesn't work.

"The public demand for fines, suspensions and firings is high, but acquiescing to public demands for justice — to ‘hang ‘em high' — will undermine culture; it won't build it," Meyer told attendees.

Such punitive measures, he argued, could also erode the joy and meaning that caretakers derive from their work, one of themes of this year's congress. Wachter countered that what really sucks the joy out of clinical work is seeing a stuffy surgeon continuously get away with ignoring the rules, which was met with applause and "amens" from the crowd.

"I think one of the things that does zap joy and meaning from the work is to see one's colleagues who are choosing not to follow important rules," he said. "You're doing it yourself and you're asking the organization, ‘Why are we not taking this seriously?' "

Interestingly, in an electronic poll taken after the debate, Wacther was declared the winner by a landslide, garnering 80 percent of the vote.

Where do you stand on this issue? Do you think the days of blame-free culture are over and noncompliant doctors should be punished, or are education and encouragement the best remedy? Leave your thoughts in the comment section below, and watch for my final report from the NPSF Congress on Monday.