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

Abstract

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 organisation's 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 Dewey's 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.

Walking the tightrope: how rebels “do” quality of care in healthcare organizations

“…Our situated approach to articulating quality rebels does explicitly involve re-evaluating the autonomousor stubbornclinician unwilling to account to "others". On the contrary, we see rebels being highly willing to account for their work, but to do so in alternative ways, such as within the media and through the networks that they build, because their practices often fit uneasily with contemporary system quality thinking that exerts control over care provision (Hollnagel et al, 2013;Pedersen, 2016). Moreover, accounting for clinical work in the rebel version is "generative" ( Jerak-Zuiderent, 2013), in the sense that it is directly linked to the goals they are pursuing and tied into the networks that they create.…”

Use or Abuse? A Qualitative Study of Emergency Physicians' Views on Use of Observation Stays at Three Hospitals in the United States and England

“…But we would caution against this: it was evident from our interviews that emergency physicians did not take decisions to observe lightly, and that if forced to discharge, there was real potential for adverse outcomes in the short term, and increased resource use in the long term. Recent thinking in safety science has noted the place of adaptability in response to clinical uncertainty, 37,40,41 and the pragmatic use of observation status by the physicians in this study might be seen as exemplifying such mindful, professional flexibility. Any rush to further formalize use of observation status may thus be ill-advisedand seeking to expand observation status to account for the breadth of purposes to which it is put in practice may have just as many unintended consequences as efforts to tighten eligibility and 'legislate out' such uses.…”

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

“…Uncertainty is an inherent feature of health, illness and care practices. ‘It is never possible to know with certainty whether a particular diagnosis is final, whether a procedure will produce the desired result, whether a patient will follow the treatment plan or whether an apparently stable and safe situation remains so’ (Pedersen 2016, p. 9). In health care, uncertainty co‐produces and is bound by the dialectic between structure and practice.…”