A transactional approach to patient safety: understanding safe care as a collaborative accomplishment

ABSTRACT

Within the last two decades, it has been commonly agreed that patient safety and error management in healthcare organizations can best be attained by adopting a systems approach via re-engineering efforts and the introduction of industrial safety technologies and methodologies. This strategy has not delivered the expected result. Based on John Dewey’s pragmatism, we propose another vocabulary for understanding, inquiring into and learning from safety situations in healthcare. Drawing especially on Dewey’s understanding of transaction as the inseparability between human and environment, we develop an analytical approach to patient safety understood as a transactional accomplishment thoroughly dependent on the quality of situated and shared habits and collaborative practices in healthcare. We further illustrate methodologically how a transactional attitude can be situationally practised through video-reflexive ethnography, a method that allows for inquiry into mundane safety practices by letting interprofessional teams see, reflect upon and possibly modify their shared practices and safety habits.

KEYWORDS:

• Transaction
• patient safety
• systems approach
• video-reflexive ethnography
• collaborative practices
• pragmatism

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Notes

1. Although Dewey sought to overcome the dichotomy between human and environment from the beginning of his career, it was only in his 1949 book Knowing and the Known, with Bentley, that he began using the word transaction. Previously, Dewey used the word interaction (see e.g., Dewey, 1922).

2. This transactional perspective is largely in line with, and has hugely inspired, actor-network-theory’s principle of generalized symmetry, which states that the relation between human and non-human actors is an empirical question, not an a priori distinction (Latour, 2005), as well as notions such as ‘socio-material entanglement’ (Mol, 2002) and ‘distributed agency’ (Callon, 1986). More specifically, Barad (2007) proposed the concept of intra-action, with intentions similar to those of Dewey and Bentley. Intra-action is also supposed to replace interaction as a concept that presupposes pre-established bodies or entities that are interrelating. Thus, intra-action understands agency as a dynamism of forces and not as an inherent property of any entity (whether humans or technologies/systems).

3. Dewey was not alone in his interest in habits; both James and Pierce were also extensively engaged in discussions about habituation. It has even been argued that pragmatism in general is essentially concerned with neither cognition nor praxis as the end goal of inquiry, but with the production of habits (Hickman, 2007, p. 244).

4. Parents were informed that their child was admitted to a NICU that participated in a quality development project and that while filming the staff, their child could be captured on camera. Therefore, their consent was requested. It was stressed, that not giving consent would have no implications for the quality of the treatment and care of their child. They had the option to withdraw at any giving moment after giving their consent. In this paper, we show no pictures of patients.

5. Adapted from Mesman et al. (2019).

6. It was this impossibility of modifying habits by thought that led to Dewey’s yearlong fascination with the work of the Australian educator Frederick M. Alexander, who had invented a technique for increasing awareness and modification of bodily habits, now known as the Alexander technique. With very close affinity to the idea of ‘situated distance’ of the VRE method, Alexander (1932) had experienced – among other techniques – that the use of mirrors could help bring about awareness of unsound bodily habits.

Additional information

Notes on contributors

Kirstine Z. Pedersen

Kirstine Zinck Pedersen is Associate Professor at Department of Organization, Copenhagen Business School, Denmark. Her research attends to the organizational, practical, and ethical implications of recent managerial and technological transformations of the public sector and in particular to the constitutive effects and unintended consequences of quality and safety programs in healthcare. Methodologically, these are studies that often combine ethnographic investigation or historical analysis with an analytical interest in American pragmatism, classic organization theory and sociological perspectives on professional work, clinical judgment and public office holding. Kirstine Zinck Pedersen is the author of Organizing Patient Safety: Failsafe Fantasies and Pragmatic Practices (Palgrave Macmillan, 2018).

Jessica Mesman

Jessica Mesman is Associate Professor at the Department of Society Studies at Maastricht University in the Netherlands. Her field of expertise is Science and Technology Studies with a focus on medical practices. In her research she tries to unpack ordinary processes (exnovation) that are traditionally neglected in order to gain insight in their role in generating and stabilizing practices. To do so she uses video-reflexive ethnography (VRE) as an interventionist and collaborative method. During the last years she has applied this approach on studying patient safety practices in healthcare settings, like emergency departments, surgical theatres and intensive care units.