Kirstine Zinck Pedersen

Standardisation or resilience? The paradox of stability and change in patient safety

This article explores an apparent paradox of stability and change in patient safety thinking and practice. The dominant approach to patient safety has largely been focused on closing safety gaps through standardisation in seemingly stable healthcare systems. However, the presupposition of system stability and predictability is presently being challenged by critics who insist that healthcare systems are complex and changing entities, thereby shifting focus towards the healthcare organisations resilient and adaptive capacities. Based on a close reading of predominant patient safety literature, the article analyses how a separation between stability and change is articulated in ontological, historical, and situated terms, and it suggests the way in which predetermining healthcare settings as either stable or unstable paves the way for a system engineering approach to patient safety that pre-empts certain types of safety solutions. Drawing on John Deweys influential ideas about the interconnectedness of stability and change, this prescriptive perspective is discussed and challenged. It is suggested that only by rethinking the relationship between change and stability can patient safety efforts begin to address the uncertainty of medical practice as well as the necessary competences of healthcare professionals to act with safety dispositions as a precondition for delivering safe care.

“The new patient”: the emergence of a political persona

Purpose n n n n nThe purpose of this paper is to explore how the patient comes to be seen as a solution to governance problems. n n n n nDesign/methodology/approach n n n n nThe paper studies health policy discourse in Denmark from 1970 to 2000. Based on an analysis of national policy documents, the paper traces how the patient is redefined as part of governance problems. n n n n nFindings n n n n nThe paper suggests that “the new patient” coincides with changes in healthcare governance and is not just a clinical concern. The persona of the patient has been mobilized in dissimilar ways in addressing specific policy problems, resulting in both a duty-based idea of a socio-economically responsible patient and a rights-based idea of a demanding health-service consumer. n n n n nResearch limitations/implications n n n n nThe study is limited to policy documents that address healthcare governance in one country. It does not describe the broader evolution of patient ideas or the practical impact of political discourses. n n n n nPractical implications n n n n nPractitioners should expect to encounter conflicting views of patient responsibilities, interests and involvement. Such conflicts are not only related to a lack of conceptual clarity but are indicative of how the new, active and responsible patient has become a key clinical concern and a central element of health policy governance. n n n n nOriginality/value n n n n nThe paper contributes to the understanding of “the new patient” in discussions on patient-centred healthcare and empowerment by emphasizing the definition of the patient in a political context. The latter has often been ignored in existing research.

Studying Patient Safety: An Introduction

Under headlines such as human factors, ‘non-blame’ and systems thinking, mainstream patient safety thinking and practice is, on the one hand, made up of a number of dominating presuppositions about human nature, risk and organizational reality, and, on the other, concrete technologies for incident reporting, error handling and risk reduction. In this introduction, Pedersen presents her study of this international policy programme and its meeting with clinical practice. The chapter includes a description of alternative strategies for studying safety, the Danish case study on which the book is based and the ‘pragmatic stance’ of the book: a commitment to the empirical field and the problem at hand which involves problem orientation, attention to the pragmatic method of inquiry and a steady focus on practical reasoning and the actual clinical situation.

Patient Safety as Trained Dispositions and Moral Education

This concluding chapter defends the importance of education and training in the nurture and regulation of safe behaviour in healthcare. Pedersen suggests that curriculums and training programmes should approach patient safety not only as system engineering, but as inseparably connected with practical types of knowledge, acting with uncertainty, the ability to use guidelines with discernment in concrete clinical situations and the inculcation of safety dispositions, practical routines and a critical sense. The book ends by advancing a return to a more normative understanding of medical practice where evaluating, taking responsibility for and forgiving or blaming medical errors within the medical community is approached as a fundamentally moral structure that supports learning through modification of dispositions and the establishment of limits of office.

Failsafe Systems and Practical Reasoning

This chapter identifies a main tension between a systemic and often simplistic ‘scientific’ stance of knowledge represented by mainstream patient safety thinking and a practical, pragmatic and case-based understanding of medical reasoning. Pedersen describes the patient safety programme’s failsafe and positivist ambitions promoted through enthusiastic advocacy, popular idioms and organizational tools, such as the Institute of Medicine’s report To Err Is Human, The Swiss Cheese Model and the Root Cause Analysis. Juxtaposing the knowledge conceptions of the safety programme, Pedersen introduces the practical philosophies of Aristotle, John Dewey and Stephen Toulmin in order to depict clinical knowledge as inseparable from acting in actual clinical situations where rules such as ‘evidence’ and guidelines are to be related to the situated and developing knowledge of concrete cases.

Stability and Change in Patient Safety

This chapter explores an apparent paradox of stability and change in patient safety thinking and practice. While dominant approaches to patient safety portray healthcare systems as relatively stable, medical errors as preventable and standardization as the pre-eminent solution to safety problems, a new resilience engineering approach—Safety II—presents safety as the ability to adapt to ever-changing and complex surroundings. By analysing a factor-ten drug prescription error and the subsequent root cause analysis, Pedersen examines how available approaches to patient safety management reproduce an illusion of certainty by maintaining a separation of stabile and changing healthcare settings. In response, John Dewey (Experience and Nature. New York: Dover Publications, 1925) and Charles Perrow (Complex Organizations: A Critical Essay. USA: McGraw-Hill Publishers, 1972; Normal Accidents: Living with High-Risk Technologies. Princeton, NJ: Princeton University Press, 1984) are cited for suggesting a more subtle and mutually constituent relationship between rules and discretion, standards and flexibility.

A Pragmatic Stance on Safety Management

The chapter draws the contours of an alternative way of approaching the problem of patient safety by presenting a range of contemporary authors who all posit a pragmatic stance on safety management (Holmes, California Law Review, 92(2), 301–356, 2009; Law, Ladbroke Grove: Or How to Think About Failing Systems. Centre for Science Studies, Lancaster University, UK, 2000; Mesman, Uncertainty and Medical Innovation: Experienced Pioneers in Neonatal Care. Basingstoke, UK: Palgrave Macmillan, 2008). Based on these and on the empirical analyses and practical attitudes developed throughout the book, a non-dichotomizing, situated and case-based alternative to the dominant system-engineering approach to safety and improvement practices in healthcare takes shape. Accordingly, Pedersen formulates three axioms to function as rules of thumb for safety management in concrete clinical situations: (1) take point of departure in the clinical situation; (2) be cautious about ideals of risk elimination through system improvements; and (3) preserve the importance of existing practices, habits and experiences.

The Oral Syringe Case

The best way to get acquainted with patient safety thinking and practice is by empirical example. In this chapter Pedersen investigates the introduction of a failsafe device—syringes for oral drug administration—in a medical centre and shows that although the healthcare professionals were persuaded to adopt and use the new safety system, the implementation of the device had massive unwanted consequences in terms of coordination problems, economic problems and new risks to patient safety. The chapter further displays how the failsafe vision of the patient safety programme and its system-engineering efforts risk challenging the training and nurture of important safety dispositions and routines in healthcare.

The Distributed Risks of Safety Management

Mainstream patient safety thinking is dominated by a faith in the possibility of risk elimination and failsafe organization. This chapter shows that rather than being eliminated, safety risks and organizational problems are likely to be redistributed when patient safety measures are introduced in clinical practice. Through empirical and analytical investigation, four categories of potentially unwanted consequences are identified: classification risk, second-order risk, standardization risk and responsibility risk. It is further argued that all four of these categories can be linked to the highly principle-based nature of the patient safety programme, which is likely to reduce the possibility of addressing safety issues with a more situated and pragmatic stance.

Blame and Responsibility in Patient Safety

It is a key assumption within mainstream patient safety literature that healthcare is dominated by a culture of blame. To test this claim, Pedersen presents empirical studies on medical training, internal error regulation and clinical safety culture by medical sociologists Rene Fox, Charles Bosk, Marianne Paget and Marilynn Rosenthal. Here, the image of a person-centred and blame-inducing clinical culture is fundamentally contested. Rather, the analysis reveals a delicate ecology of co-collegial observation, classification and management of different sorts of errors, mistakes and misconduct, where the uncertain, time-dependent and fallible character of medical knowledge has such an effect that incompetence and malpractice are sometimes hard to identify. By rearticulating these traditional modes of error management within the professional community, Pedersen challenges current blame-free strategies of safety management.