Back to basics: Governing antibacterial resistance by means of mundane technoscience and accountability relations in a context of risk

Abstract

In 2006, a sudden spread of a strain of a multi-resistant bacterium (Klebsiella pneumonia ESBL) arose inside of the Swedish university hospital in Uppsala. Measures of risk management were taken immediately to fight the bacteria spread in order to stop what soon developed into an epidemic. Officers at the hospital initiated a system of accountability relations, in this article analysed through a model developed by Neyland and Woolgar. We show how the introduction of mundane technoscientific procedures was closely related to efforts of making them understandable, recognisable, relevant and necessary to the actors involved. One and a half year later, the hospital declared the measures taken a success. Abeneficial change of behaviour and practices among the employees, patients and visitors had occurred. Furthermore, the prescription of antibiotics had decreased and become more appropriate and additional rooms with their own sanitary facilities were available. Although succeeding in halting the epidemic, both the implementation and above all the sustainability of the accountability system proved exceedingly exigent. However, to uphold an adequate practice and behaviour in the long run, the system needs constant management and monitoring. Well aware of this difficulty, the officers had the intention of creating a new, self-supporting culture. So far, the ambition of achieving consistent and persistent norms and a new culture seems to have failed. Our conclusions are ofrelevance for understanding how systems of accountability may be used in risk management.

Keywords:

• risk
• risk management
• accountability
• mundane technoscience
• governance
• antibiotic resistance

Acknowledgements

This research is supported by a grant from the Swedish Research Council (dnr 2007-1633). We would also like to thank the employees of UAS for their generosity while we conducted the research, giving us access to material and opportunities for interviews. We are especially grateful to Dr. Torbjörn Söderström and Dr. Birgitta Lytsy for their help.

Notes

1. With departments established as early as the sixteenth century, Uppsala Akademiska Sjukhus (UAS) is Sweden's oldest university hospital. Today, UAS is a full-scale university hospital with 1200 beds, 8000 employees and more than 300,000 physician encounters yearly. Being an advanced training, research and specialist hospital, it also serves the county of Uppsala.

2. The notion of accountability is but one out of many important concepts and approaches associated with ethnomethodology. Others are, for instance, the notions of reflexivity, indexicality or the documentary method. The ethnomethodological research and theoretical discussions are immense. For two classical texts, see Garfinkel 1967, 2002. For introductions, see Lynch and Peyrot 1992, Linstead 2006. For a volume of recent empirical work, see Hester and Francis 2007. Please also note that the accountability concept is not restricted to ethnomethodological approaches alone but is used in many academic and non-academic contexts.

3. Presented in this way, the notion of accountability has been important in the field of organisational studies. Arguing that large companies and public sector organisations have to deal with sometimes deeply rooted social practices, insights of the function of giving and receiving accounts is imperative to understand management. From this point of view, Munro and Mouritsen (1996) offer more than a dozen case studies of accountability, although theoretically not informed by only ethnomethodology.

4. The model is, of course, also informed by earlier research of different modes of accountability. Suchman (1993) has shown how monitoring of aircraft movement by air-traffic control officers is oriented not only to pilots and the support crew at the airport but also to other parties through a nationwide computer system. Button and Sharrock (1998) studied how engineers in large-scale technological projects, through organisational accountability, make their actions accessible to relevant parties with in the project. Neyland and Woolgar (2002) have studied what they call the ‘messiness of accountability in action’ in a database purchasing decision. Also see Neyland's (2007) study on how transparency reviews do not straightforwardly open up opportunities to render an organisation accountable. Luff and Heath (1993) have shown how a number of actors are accounted for outside an architectural practice.

5. Lex Maria is a clause in the Swedish Act of the Health Care Professions, requesting healthcare providers to notify the National Board of Health and Welfare whena patient has been affected by or exposed to risk in the context of health care. The name comes from an incident in 1936 when four patients at the Maria Hospital in Stockholm died as a result of medical errors and maltreatment. (see Swedish Statute book 1998:531, chapter 6, § 4).

6. Supported by the Swedish government, Strama is a collaborative body with the remit of working for interdisciplinary collaboration in issues related to safeguarding the possibility of effective use of antibiotics in human and veterinary bacterial infections ( http://www.strama.se).

7. The graph is published by courtesy of medical director and Ph.D. Birgitta Lytsy at the UAS.