International Journal for Quality in Health Care Advance Access originally published online on August 23, 2007
International Journal for Quality in Health Care 2007 19(5):257-258; doi:10.1093/intqhc/mzm035
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Editorial |
Getting to the ‘roots’ of patient safety
E-mail: jj_waring{at}hotmail.com, justin.j.waring{at}man.ac.uk
As noted recently within this journal, quality improvement evaluations need to be theoretically informed if they are to have meaning and value to service improvement [1]. The same is true of how we understand the sources of quality or, conversely, poor quality. Over the last 15 or so years there has been somewhat of a seismic shift in thinking about risk within healthcare. This can be found in health policies across the world articulated within the discourse of ‘patient safety’. However, questions should be asked about how far this approach, especially as it is practiced as a method of organizational learning, really engages with the underlying causes of risk and whether service leaders are really in a position to make the changes necessary to raise service quality.
It is argued that, in the past, clinical errors were too often seen as resulting from erroneous and incompetent human behaviour. Current thinking counters this ‘person centres’ view by revealing how human error is often conditioned by wider contextual factors [2]. This ‘systems approach’ draws from the Human Factors approach to make a conceptual distinction between ‘active errors’, manifest within individual practice, and ‘latent factors’, located ‘upstream’ within the work setting [3]. These latent factors are seen as enabling or exacerbating the potential for human error, and accordingly should be the focus of safety improvements. As an approach to organizational learning this is often associated with the practice of ‘root cause analysis’ [3], which directs service leaders to seek out, and manage, the ‘root’ causes of risk through a series of ‘why questions’ [4, 5].
Although these ideas certainly counter the preoccupation with individual responsibility and blame, questions need to be asked about how far they really look beyond the individual and whether, in practice, it is feasible to tackle the ‘root’ causes of clinical risk.
It is easy to appreciate that with its grounding in social psychology and its concern to identify the factors that produce human error, the prevailing approach can have an overriding focus on the psycho-social context of clinical work. In other words, individual behaviour remains the focus of attention, albeit in a systemic context. Hence safety improvements centre on making changes within the immediate clinical environment to control for the factors that produce human error. This involves, for example, introducing safety checks and warning alarms, standardizing tasks and introducing guidelines or automating activities [5].
What we find is that much of the mainstream research is, in a sense, myopic in its focus, tending to conflate or reduce analysis to the psycho-social, rather than considering the distinct and inter-connected factors manifest within the cultural, organizational and institutional context of work. Although much is written about ‘root causes’ factors, these underlying roots are rarely developed theoretically or analytically. It is important therefore to look to other approaches that can help us dig deeper to the ‘roots’ of safety.
One of the most influential studies of organizational risk is Perrow's Normal Accident Theory [6]. This was developed through an investigation of the system failures that contributed to the Three Mile Island nuclear disaster. This work surfaces how discrete and apparently isolated failures within complex systems can interact in unanticipated ways leading to ‘normal’ accidents. This is pronounced where this is a high degree of ‘interactive complexity’, where there are multiple inter-connecting tasks, that are ‘tightly coupled’ or highly inter-dependant. Through examining how organizations are structured in this way, it becomes possible to appreciate how failures or mistakes in one setting can cascade, culminating in more profound risks.
While resonating with the Human Factors approach [3], these ideas are rarely applied within healthcare research. Yet this approach has much to offer. For example, hospitals are highly complex organizations with patient care involving numerous resource-dependant exchanges between specialized departments and wards. This interactive context can mean that small failures in one setting can spill out into others producing and compounding factors such as time pressures and communication breakdowns. This is explored in one recent operating department study. This reveals how the structured interactions between the operating room, surgical wards, histopathology and other support departments can combine to produce accumulated risks; the roots of which, those at the frontline professionals, have little scope to recognize or deal with [7].
Another major work in this area is Vaughan's study of organizational ‘dark sides’. Initially developed with reference to the Challenger Space Shuttle Disaster [8], this highlights that the sources of error and disaster are often located deep within the social organization of work. This extends beyond the psycho-social realm to consider more fully the socio-cultural and institutional context of work [8]. These ideas have been tentatively applied to healthcare [9, 10] to reveal how the division of labour or communication arrangements can frame safety. It also helps bring to the fore the importance of institutional pressures, such as political demands and economic constraints. As well as the role of culture, especially the way shared norms and ritualistic practices can encourage staff to normalize risk, which has recently been shown within the healthcare context [11].
Such theories more effectively engage with the deeper ‘roots’ of safety. They broaden the analytical lens to offer more fundamental opportunities for safety improvement that extend beyond those that directly shape individual or group behaviour. Although these are acknowledged within mainstream research [10], they are rarely developed analytically and there remains a need for further research in these areas. These theories also question how far or how deep activities such as Root Cause Analysis are currently undertaken. In other words, service leaders should perhaps ask more ‘why’ questions to identify the underlying systemic factors. However, it is important to recognize the limited capacity for service leaders to truly appreciate and tackle risks that are rooted in systems and institutional arrangements beyond their control. This means that while we should widen our analytical lens for research, we also need to encourage and empower national agencies to effectively initiate change at the appropriate levels.
Medical Sociology and Health Policy, School of Sociology and Social Policy, University of Nottingham, University Park, Nottingham NG7 2RD, UK
References
- Walshe K. Understanding what works—and why—in quality improvement: the need for theory-driven evaluation. Int J Qual Health Care (2007) 19:57–9.
[Free Full Text] - Reason J. Human error: model and management. BMJ (2000) 320:768–70.
[Free Full Text] - Reason J. Managing the Risks of Organizational Accidents (1997) Aldershot: Ashgate.
- Latino R, Latino K. Root Cause Analysis: Improving Performance for Bottom-Up Results (2006) London: Taylor-Francis.
- National Patient Safety Agency. Seven Steps to Patient Safety (2004) London: National Patient Safety Agency.
- Perrow C. Normal Accidents: Living with High-Risk Technology (2004) New York: Basic Books.
- Waring J, McDonald R, Harrison S. Safety and Complexity: inter-departmental relationships as a threat to patient safety in the operating department. J Health Organ Manag (2006) 20:227–42.[CrossRef][Medline]
- Vaughan D. The dark side of organizations: mistakes, misconduct, disaster. Ann Rev Sociol (1999) 25:271–305.[CrossRef][Web of Science]
- West E. Sociological contributions to patient safety. In: Patient Safety: Research into Practice—Walshe K, Boaden R., eds. (2006) Buckingham: Open University Press.
- Vincent C. Risk, safety and the dark side of quality. BMJ (1997) 314:1775.
[Free Full Text] - Waring J, Harrison S, McDonald R. A culture of safety or coping: ritualistic behaviours in the operating theatre. J Health Serv Res Polic (2007) 12:3–9.[CrossRef]
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