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One event, three investigations: The reproduction of a safety norm : The reproduction of a safety norm

Wrigstad, Jonas LU ; Bergström, Johan LU and Gustafson, Pelle LU (2017) In Safety Science 96. p.75-83
Abstract
Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amounts of time and resources, all three investigations make the same analytical choice to construct the causal factors as a deviation from norm in the event's immediate temporal and spatial proximity. We recognise that this both represents a strong discourse in the community analysing adverse events and seems to fulfil certain psychological purposes.... (More)
Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amounts of time and resources, all three investigations make the same analytical choice to construct the causal factors as a deviation from norm in the event's immediate temporal and spatial proximity. We recognise that this both represents a strong discourse in the community analysing adverse events and seems to fulfil certain psychological purposes. Furthermore, we suggest that thorough analysis of adverse events in healthcare need to include aspects of system interaction from the micro to the macro, cognitive work configuration and design, as well as variability as a resource to harness rather than a threat to limit and control. (Less)
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author
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
adverse event, Safety norm, Healthcare, Discourse;, Causal factor, Investigation
in
Safety Science
volume
96
pages
9 pages
publisher
Elsevier
external identifiers
  • scopus:85015805938
ISSN
0925-7535
language
English
LU publication?
yes
id
9cb12bb1-e16c-4618-8499-751d19fbd079
date added to LUP
2017-03-21 08:55:17
date last changed
2017-06-25 05:00:42
@article{9cb12bb1-e16c-4618-8499-751d19fbd079,
  abstract     = {Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amounts of time and resources, all three investigations make the same analytical choice to construct the causal factors as a deviation from norm in the event's immediate temporal and spatial proximity. We recognise that this both represents a strong discourse in the community analysing adverse events and seems to fulfil certain psychological purposes. Furthermore, we suggest that thorough analysis of adverse events in healthcare need to include aspects of system interaction from the micro to the macro, cognitive work configuration and design, as well as variability as a resource to harness rather than a threat to limit and control.},
  author       = {Wrigstad, Jonas and Bergström, Johan and Gustafson, Pelle},
  issn         = {0925-7535},
  keyword      = {adverse event,Safety norm,Healthcare,Discourse;,Causal factor, Investigation},
  language     = {eng},
  pages        = {75--83},
  publisher    = {Elsevier},
  series       = {Safety Science},
  title        = {One event, three investigations: The reproduction of a safety norm :  The reproduction of a safety norm},
  volume       = {96},
  year         = {2017},
}