Understanding safety agendas is a key principle that informs healthcare’s
organisational directives to improve patient safety. As such, standardised RCA processes are endorsed, yet as a social group, healthcare departs from safety agendas that announce a standardise process to improve safety. The view here is that although legislative conditions are complex and organisational directives aspire to locate human error and identify latent failures, there is “divergence in analytical processes” (Schulman, 1993, p. 364) that is collective. This draws on an idea that the RCA is theoretically informed and socially constructed. Yet, conversely, the collective view to improve patient safety that draws on clinical knowledge, experience and learning to identify error, departs from system safety ideas. As noted, Perrow’s (1984) Normal Accident theory asserts that accidents are rare events although normal in complex organisations. In addition and more explicitly defined, healthcare’s safety directives draw on Reason’s system/person approach where active and latent failures are mapped to form error trajectories. To these trajectories, the 5Why’s principles are located. Thus, clear directives emerge that theoretically identify system safety constructs. The point is organisational directives provide standardised methods to the application of an RCA as noted above. Yet, the data revealed despite these theoretical agendas, the application of an RCA was lacking in a systems approach. The issue is that standardisation, the agendas that drive the RCA, are avoided in healthcare.
The idea that healthcare fails to support approved agendas, is alarming and a full explanation cannot be gathered from this research. Nonetheless, there was a collective view in the RCAs that non-compliance to rules was accepted and these risky behaviours
(Vaughan, 1999) are supported. More specifically, it is not only that non-compliance to rules is accepted, but non-compliance to standardised policies has normalised in healthcare. A pattern emerges where there is a culture in healthcare to acknowledge rules but at the same customises (Welch & Jensen, 2007) the rules to make them fit. This means that
organisational policies, procedures and guidelines are manipulated to suit local conditions
which is challenging in terms of patient safety because concepts of organisational safety can be worked around. This appeared in the RCA. It is predicted that these departures from policy are not intended to cause harm. Yet, on returning to the data, the data typically revealed that harm resulted from active errors where standardised processes were not applied and the other approach resulted unexpectedly, in harm. These actions are similar to enabling characteristics where an RCA is not mandated for a reportable event and learnings from harm can be acquired through other techniques. The issue is that rules are either intentionally ignored or modified because healthcare is a “hero-seeking” organisation where health professionals “overestimate their knowledge” (Rochlin, 1999, p. 1557) and safety activities are compromised. Rowley (2011) in part, identifies with this phenomenon claiming that
“deviantly innovative” acts that depart from standardised practice can be advantageous and advance medical knowledge (Rowley, 2011, p.95). As noted, while advances in medical knowledge were not identified as causal factors in the RCA, what was revealed was that standardised procedures were modified, patient harm resulted and RCA recommendations announced the development of further organisational procedures. A clear dichotomy prevails where patient safety is characterised by individual efforts.
Returning to theoretical safety frames and the idea that RCA legislation fails to address safety and the notion of hero-seeking (Rochlin, 1999) an impasse forms where the application of theoretical views in the RCA creates conceptual safety chaos. To explain this by drawing on healthcare’s safety ideas, in high reliability organisations, non-compliance to rules is not typically accepted, but is managed. In Normal Accident theory, rule violations are tolerated because the notion of social redundancy acknowledges that problems are overlooked (Tamuz & Harrison, 2006). Departing from organisational rules by customising (Welch & Jensen, 2000) procedures through decision making processes where it cannot be predicted that potential interactions or unexpected outcomes may arise, is routine in Normal Accident theory (Perrow, 1984). From a system/person approach (Reason, 1990) individual clinical judgements are supported, but not regulated by RCA legislation or by organisational safety concepts. As such, healthcare’s safety perspective grants a level of autonomy that extends beyond specified policies and procedures and beyond theoretical safety models because changing patients’ needs are a priority. This is how concepts of safety are adapted to best fit clinical demands.
Thus, RCAs systems approach is challenged because the social construction of the RCA cannot explain how dedicated health professionals adapt rules that result in harm again and again. The problem is that safety cannot be predicted through the RCA because the RCA does not clarify why active errors are abound or why organisational rules are overlooked or
why individual recurring safety deviations that result in harm are disregarded. Thus, human errors that result in harm are being ignored by the RCA. Moreover, the notion of avoiding standardised procedures is at a point where the RCA departs as a technique to learn from harm and improve patient safety because theoretical safety agendas cannot be applied while safety is an obscure construct in healthcare. There is a culture in healthcare where medical autonomy is accepted in the event of harm but this disrupts teamwork (Shortell & Singer, 2008) and is counterproductive to apply theoretical safety agendas. More specifically, healthcare is unable to translate the interactive dynamics of hero-seeking into theoretical safety ideas to inform the RCA.
In closing, safety agendas cannot be translated into practice because the principles that inform each safety concept are divergent and one approach cannot be converted into healthcare’s RCA. Moreover, a systems approach is not possible because standardisation is not collectively attended and there is a culture in healthcare to customise organisational rules and this is contradictory to improve patient safety. These ideas draw on Schulman’s (1993) notion of “conceptual slack” where a level of autonomy departs from systemic goals (Schulman, 1993, p. 364). More precisely, conceptual slack (Schulman, 1993) occurs when an interpretive approach to theoretical patient safety agendas is applied. For patient safety and the RCA, individual safety ideas and an autonomous clinical environment that result in error and harm are consistent with notions of conceptual slack. Further, bureaucratic influences have shifted a “locus of control” (Rochlin, 1996, p. 1554) from official promises to improve patient safety to individuals. As noted, there is a culture of autonomy in
healthcare that disrupts a systems approach. As a result, safety constructs are perceived to occur. For this reason a systems approach is not underpinned by theoretical safety agendas but by clinical needs and clinical autonomy. To that end, a variety of theoretical safety ideas shape the RCA but no explicit safety agenda is applied. Thus, there is an illusion that the RCA is buttressed by safety principles but in application the social view of the RCA is burdened by conflicting regulatory agendas and a culture where autonomy of clinicians self-governs patient safety.
In Queensland, the function of the RCA to improve patient safety is contentious because system risks are abandoned and theoretical safety agendas underpinned by a systems approach are not applied and notions of conceptual slack (Schulman, 1993) cannot be ignored. Queensland Health’s systematic process of analysis (Queensland Health, 2009b) is problematic because the “determination of systemic causes to prevent recurrences of adverse events” (Percarpio et al., 2008, p 391) is absent. Hence, a safer system cannot be predicted.
As a result, the RCA is not a report informed by a systems approach but is a report of social
significance. It is recommended that patient safety be reaffirmed as a priority in the following way:
Recommendation 2
1. Develop regulatory documents linked to organisational patient safety outcomes to specifically address matters of compliance and autonomy of clinicians.
a. Relinquish no-blame frameworks and assign levels of accountability to healthcare facilities that are rewarded.
2. Introduce frameworks to move patient safety investigations from mono-causal methods to systematic processes (Fahlbruch, 2011).
i. Develop a system based event analysis technique to address latent system failures.
ii. Include clinical staff to inform data gathering processes.
iii. Listen to and involve consumers in the process of healthcare incident analysis is recommended (Ocloo, 2011).
iv. A modified approach will:
1. Undertake preliminary investigations that engage frontline staff and develop resident solutions for localised latent failures.
2. Apply a matrix approach (Fahlbruch, 2011) to make clear a framework for a sustained investigation.
3. Enlist a specialist incident analysis team to the investigation of SAC 1 harm to deactivate bureaucratic tensions and limit collegial examination of practice.
4. Develop new safety agendas to frame an investigation of an event that are compatible with new legislative frameworks.
5. The Australian Commission of Safety and Quality to address definitions of harm to clarify inevitable or avoidable harm (Noble & Pronovost, 2010).