One event, three investigations : The reproduction of a safety norm
(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)
Please use this url to cite or link to this publication:
https://lup.lub.lu.se/record/9cb12bb1-e16c-4618-8499-751d19fbd079
- author
- Wrigstad, Jonas LU ; Bergström, Johan LU and Gustafson, Pelle LU
- organization
- publishing date
- 2017-03
- 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
- wos:000401392500007
- ISSN
- 0925-7535
- DOI
- 10.1016/j.ssci.2017.03.009
- language
- English
- LU publication?
- yes
- id
- 9cb12bb1-e16c-4618-8499-751d19fbd079
- date added to LUP
- 2017-03-21 08:55:17
- date last changed
- 2022-04-01 07:46:52
@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}},
keywords = {{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}},
url = {{https://lup.lub.lu.se/search/files/22881386/One_event_three_investigation.pdf}},
doi = {{10.1016/j.ssci.2017.03.009}},
volume = {{96}},
year = {{2017}},
}