Design-based regulation and patient safety: a regulatory studies perspective

Persistent institutional breaches: Technology use in healthcare work

Various mobile phone applications (hereafter apps) challenge instituted ways of working in healthcare. This study explores the institutional breaches arising from the use of apps in doctor-patient interactions. This paper argues that institutional breaches, however small, are important occasions for observing the contextual intersections between healthcare, regulation and technology in a hospital setting. Based on healthcare professionals' normative judgements, the paper offers an empirically grounded understanding of institutional legitimacy-claiming; safeguarding responses deployed by the instituted regime, and the case-building responses deployed by the instituting persuaders. Institutional breach persistence arises from the moral dimension of legitimacy and is grounded in asymmetrical dynamics between two virtuous healthcare narratives. The paper concludes with a discussion of the contextual intersections between healthcare, regulation and technology, paying particular attention to institutional breaches as experimentation, the contestation of normativity and patterns of technology indulgency in healthcare work.

How not to waste a crisis: a qualitative study of problem definition and its consequences in three hospitals

Objectives

The prominence given to issues of patient safety in health care organizations varies, but little is known about how or why this variation occurs. We sought to compare and contrast how three English hospitals came to identify, prioritize and address patient safety issues, drawing on insights from the sociological and political science literature on the process of problem definition.

Methods

In-depth qualitative fieldwork, involving 99 interviews, 246 hours of ethnographic observation, and document collection, was carried out in three case-study hospitals as part of a wider mixed-methods study. Data analysis was based on the constant comparative method.

Results

How problems of patient safety came to be recognized, conceptualized, prioritized and matched to solutions varied across the three hospitals. In each organization, it took certain ‘triggers’ to problematize safety, with crises having a particularly important role. How problems were constructed – and whose definitions were prioritized in the process – was highly consequential for organizational response, influencing which solutions were seen as most appropriate, and allocation of responsibility for implementing them.

Conclusions

A process of problem definition is crucial to raising the profile of patient safety and to rendering problems amenable to intervention. How problems of patient safety are defined and constructed is highly consequential, influencing selection of solutions and their likely sustainability.

People, systems and safety: resilience and excellence in healthcare practice

This article outlines recent developments in safety science. It describes the progression of three ‘ages’ of safety, namely the ‘age of technology’, the ‘age of human factors’ and the ‘age of safety management’. Safety science outside healthcare is moving from an approach focused on the analysis and management of error (‘Safety‐1’) to one which also aims to understand the inherent properties of safety systems that usually prevent accidents from occurring (‘Safety‐2’). A key factor in the understanding of safety within organisations relates to the distinction between ‘work as imagined’ and ‘work as done’. ‘Work as imagined’ assumes that if the correct standard procedures are followed, safety will follow as a matter of course. However, staff at the ‘sharp end’ of organisations know that to create safety in their work, variability is not only desirable but essential. This positive adaptability within systems that allows good outcomes in the presence of both favourable and adverse conditions is termed resilience. We argue that clinical and organisational work can be made safer, not only by addressing negative outcomes, but also by fostering excellence and promoting resilience. We outline conceptual and investigative approaches for achieving this that include ‘appreciative inquiry’, ‘positive deviance’ and excellence reporting.

Prefrontal electrical stimulation in non-depressed reduces levels of reported negative affects from daily stressors

Advances in neuroscience and pharmacology have led to improvements in the cognitive performance of people with neurological disease and other forms of cognitive decline. These same methods may also afford cognitive enhancement in people of otherwise normal cognitive abilities. “Cosmetic”, or supranormal, cognitive enhancement offers opportunities to enrich our social or financial status, our interactions with others, and the common wealth of our community. It is common to focus on the potential benefits of cognitive enhancement, while being less than clear about the possible drawbacks. Here I examine the harms or side-effects associated with a range of cognitive enhancement interventions. I propose a taxonomy of harms in cognitive enhancement, with harms classified as (neuro)biological, ethical, or societal. Biological harms are those that directly affect the person’s biological functioning, such as when a drug affects a person’s mood or autonomic function. Ethical harms are those that touch on issues such as fairness and cheating, or on erosion of autonomy and coercion. Societal harms are harms that affect whole populations, and which are normally the province of governments, such as the use of enhancement in military contexts. This taxonomy of harms will help to focus the debate around the use and regulation of cognitive enhancement. In particular it will help to clarify the appropriate network of stakeholders who should take an interest in each potential harm, and in minimizing the impact of these harms.

How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

CONTEXT

Incident-reporting systems (IRSs) are used to gather information about patient safety incidents. Despite the financial burden they imply, however,little is known about their effectiveness. This article systematically reviews the effectiveness of IRSs as a method of improving patient safety through organizational learning.

METHODS

Our systematic literature review identified 2 groups of studies: (1)those comparing the effectiveness of IRSs with other methods of error reporting and (2) those examining the effectiveness of IRSs on settings, structures, and outcomes in regard to improving patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where, and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single-loop and double-loop learning.

FINDINGS

In total, we identified 43 studies, 8 that compared IRSs with other methods and 35 that explored the effectiveness of IRSs on settings, structures,and outcomes. We did not find strong evidence that IRSs performed better than other methods. We did find some evidence of single-loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence of either improvements in outcomes or changes in the latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double-loop learning, that is, a cultural change or a change in mind-set.

CONCLUSIONS

The results indicate that IRSs could be more effective if the criteria for what counts as an incident were explicit, they were owned and ledby clinical teams rather than centralized hospital departments, and they were embedded within organizations as part of wider safety programs.

Sensemaking and the co-production of safety: a qualitative study of primary medical care patients

This study explores the ways in which patients make sense of 'safety' in the context of primary medical care. Drawing on qualitative interviews with primary care patients, we reveal patients' conceptualisation of safety as fluid, contingent, multi-dimensional, and negotiated. Participant accounts drew attention to a largely invisible and inaccessible (but taken for granted) architecture of safety, the importance of psycho-social as well as physical dimensions and the interactions between them, informal strategies for negotiating safety, and the moral dimension of safety. Participants reported being proactive in taking action to protect themselves from potential harm. The somewhat routinised and predictable nature of the primary medical care consultation, which is very different from 'one off' inpatient spells, meant that patients were not passive recipients of care. Instead they had a stock of accumulated knowledge and experience to inform their actions. In addition to highlighting the differences and similarities between hospital and primary care settings, the study suggests that a broad conceptualisation of patient safety is required, which encompasses the safety concerns of patients in primary care settings.

Enhancement, ethics and society: towards an empirical research agenda for the medical humanities and social sciences

For some time now, bioethicists have paid close attention to issues associated with 'enhancement'; specifically, the appropriate use and regulation of substances and artefacts understood by some to improve the functioning of human bodies beyond that associated with 'normal' function. Medical humanities scholars (aside from philosophers and lawyers) and social scientists have not been frequent participants in debates around enhancement, but could shine a bright light on the range of dilemmas and opportunities techniques of enhancement are purported to introduce. In this paper, we argue that empirical research into the notion and practice of enhancement is necessary and timely. Such work could fruitfully engage with-and further develop-existing conceptual repertoires within the medical humanities and social sciences in ways that would afford benefit to scholars in those disciplines. We maintain that empirical engagements could also provide important resources to bioethicists seeking to regulate new enhancements in ways that are sensitive to societal context and cultural difference. To this end, we outline an empirical agenda for the medical humanities and social sciences around enhancement, emphasising especially how science and technology studies could bring benefits to-and be benefitted by-research in this area. We also use the example of (pharmaceutical) cognitive enhancement to show how empirical studies of actual and likely enhancement practices can nuance resonant bioethical debates.

International law, public health, and the meanings of pharmaceuticalization

Recent social science scholarship has employed the term "pharmaceuticalization" in analyses of the production, circulation and use of drugs. In this paper, we seek to open up further discussion of the scope, limits and potential of this as an analytical device through consideration of the role of law and legal processes in directing pharmaceutical flows. To do so, we synthesize a range of empirical and conceptual work concerned with the relationships between access to medicines and intellectual property law. This paper suggests that alongside documenting the expansion or reduction in demand for particular drugs, analysts of pharmaceuticalization attend to the ways in which socio-legal developments change (or not) the identities of drugs, and the means through which they circulate and come to be used by states and citizens. Such scholarship has the potential to more precisely locate the biopolitical processes that shape international agendas and targets, form markets, and produce health.

Value of a modified early obstetric warning system (MEOWS) in managing maternal complications in the peripartum period: an ethnographic study

OBJECTIVE

To explore implementation of the modified early obstetric warning system (MEOWS) in practice to further understanding about the influence of contextual factors.

METHODS

An ethnographic study using observations (>120 h), semi-structured interviews (n=45) and documentary review was performed in the maternity services in two UK hospitals over a 7-month period. Doctors, midwives and managers participated in the study and data were analysed thematically.

RESULTS

For women admitted to hospital in the antenatal and postnatal period with an established risk of morbidity, the MEOWS enabled communication about vital signs from junior to senior midwives and obstetricians. The trigger prompts helped shape shared understandings of maternal complications. However, midwifery and obstetric staff questioned the added value of an extra chart in the postnatal period given the low incidence of maternal complications and the resulting increase in workload. In an effort to prioritise workload demands and respond to the immediate needs of both women and their babies, midwives exercised professional discretion regarding its use. However, discretionary use of MEOWS meant the loss of a potential universal safety net for detection of deterioration.

CONCLUSIONS

Despite a decade of use in acute settings, research into the effectiveness of early warning systems still yields conflicting results. Widespread policy support for the MEOWS is based on its intuitive appeal and no validated system for use in the maternity population currently exists. Our findings suggest that, while the MEOWS has value in structuring the surveillance of hospitalised women with an established risk of morbidity, the complexities of managing risk and safety within the maternity pathway, the associated opportunity costs of MEOWS and variation in implementation currently call into question its role for routine use.

Why is U.K. medicine no longer a self-regulating profession? The role of scandals involving "bad apple" doctors

This article identifies the role played by a series of medical scandals in the U.K., occurring from the mid-1990s onwards, in ending a collegial model of self-regulation of the medical profession that had endured for 150 years. The state's original motive in endorsing professional self-regulation was to resolve the principal-agent problem inherent in the doctor-patient relationship. The profession, in return for its self-regulating privileges, undertook to act as a reliable guarantor for the competence and conduct of each of its members. Though sufficient to ensure that most doctors were "good", the collegial model adopted by the profession left it fatally vulnerable to the problem of "bad apples": those unwilling, incapable or indifferent to delivering on their professional commitments and who betrayed the trust of both patients and peers. Weak administrative systems in the NHS failed to compensate for the defects of the collegium in controlling these individuals. The scandals both provoked and legitimised erosion of the profession's self-regulatory power. Though its vulnerability to bad apples had been present since the founding of the 19th century profession, it was the convergence of social and political conditions at a particular historical moment that transformed the scandals into an unstoppable imperative for reform. Huge public anger, the voice permitted to a coalition of critics, shifts in social attitudes, the opportunity presented for imposing standards for accountability, and the increasing ascendancy of pro-interventionist managerialist and political agendas from the early 1990s onwards were all implicated in the response made to scandals and the shape the reforms took. Scandals need to be understood not as simple determinants of change, but as one performative element in a constellation of socially contingent forces and contexts. The new rebalancing of the "countervailing powers" has dislodged the profession as the senior partner in the regulation of doctors, but may introduce new risks.