Accounting for Patient Safety: Insights from the Paradigm of “Risk Governance”

1. Accounting for Patient Safety: Insights from the Paradigm of “Risk Governance” Trenholme Junghans, M.Phil.

2. Theories of the “Risk Society” • Ulrich Beck and Anthony Giddens • Beck: • 1992: Risk Society: Towards a New Modernity • 1999: World Risk Society • Giddens: • 1990: The Consequences of Modernity • 1991: Modernity and Self-Identity: Self and Society in the Late Modern Age

3. “Risk Society” cont’d. • the current moment is characterized by a preoccupation with risk avoidance • risk is seen to increasingly derive from man-made systems rather than nature • scientific and technological expertise are seen less as potential risk ameliorators than as sources of uncertainty and insecurity

4. “Risk Society” cont’d. • shift of emphasis from “invisible to visible to virtual risks and the change in the spatial, temporal, and demographic distribution of risk giving rise to borderless risks” (Ekberg 2007: 344) • E.g., threats of nuclear contamination, biological agents, and genetically modified life forms • The probability of exposure to such risks might be low, but the potential consequences of exposure are correspondingly high -- statistically rendered

5. “Risk Society” cont’d. • the proliferation of risk definitions compromises effective risk communication • trust (particularly trust in the content of science and the conduct and governance of scientists) declines as risk is perceived to increase • the resulting ethos is one of reflexivity

6. Audit Culture and Risk Management • Michael Power • 1999 The Audit Society: rituals of verification • 2005 Organizational Encounters with Risk (ed. with Hutter) • 2007 Organized uncertainty: designing a world of risk management Marilyn Strathern • 2000 Audit Cultures: Anthropological Studies in Accountability, Ethics and the Academy

7. Patient Safety as Risk Management/Risk Governance? • a shift from an emphasis on the content of risk knowledge to the process of risk management • Inhibits the sort of “disruptive intelligence” which potentially enhances organizational performance • the triumph of a “false precision” whereby techniques of audit and measurement feed into an illusion of scientificity • by means of a pervasive atmosphere of organizational defensiveness which “defines the responsible organization as one that leaves ‘no fear unturned’”

8. “Safety” as an especially slippery epistemological object: • “Because danger is often unobservable, it is impossible to determine for certain when we are safe. As the absence of danger, safety is the absence of something that is often unobservable in the first place. While it is sometimes possible to tell when danger is present, it is impossible to tell for certain that it is completely absent. Since there are numerous ways for any item or situation to be dangerous, designating something as safe requires ignoring all possible ways it might be dangerous.” (Simpson, 1996)

9. Proposition 1 • Proposition 1: risk and safety are intrinsically unmeasurable; they can only be represented by proxy, and in the negative. At the same time, practices of risk management, audit and accountability create pressures to “fix” the unmeasurable, and hence have a tendency to mistake the measurement (proxy or sign) for the “reality” and in the process to close spaces of uncertainty and ambiguity.

10. Proposition 2 • Proposition 2: To work well, members of any team need “psychological safety” (Edmondson 1999; Fraher and others). This circumstance gains particular resonance in the case of professionals working in “risky” businesses, often referred to as High Reliability Organisations (Fraher; Weick), of which medicine is certainly one.

11. Hypothesis • Many of the efforts made to stabilize, translate and measure the inherently elusive phenomena and practices associated with patient “safety” operate at the expense of the preconditions of psychological safety required for effective teamwork in general, and the arguably heightened safety requirements of individuals and teams engaged in the “risky” work of health care provision in particular.

12. Second body of Literature: The psychodynamic literature • Tavistock Institute and the study of group relations • (Wilfred Bion, Isobel Menzies, Larry Hirschhorn, Anton Obholzer, Davide Nicolini, Yiannis Gabriel, Amy Armstrong, Amy Fraher) • Bion, 1961 Experience in Groups • Huffington et. al. 2004 Working Beneath the Surface: the emotional life of contemporary organizations • The Object Relations Tradition (Melanie Klein, D.W. Winnicott) • Winnicott, 1971 Playing and Reality

13. The psychodynamic literature, cont’d. • Bion: • The distinction between “defense” and “task” • Regarding patient safety, what happens when a defense (safety) becomes the primary task? • Winnicott: • Transitional objects, experiences, and spaces • Regarding patient safety, what happens when these vital spaces are closed?