Reflection

Reviewing the evolution of patient safety over time, we see a discursive shift from harm to “error.” The “error” framing is used to advance the authority of scientific-bureaucratic managerial medicine and to diminish the traditional authority of clinical expertise. Psychologist Sidney Dekker noted that four different voices appear in patient safety discourses: epistemological (what happened?), preventative (how can it be prevented?), boundary-maintaining (were there violations or impermissible activities?), and existential (what is the reason for this suffering?). Discussions in one voice tend to be dissatisfying for the others, but the “error” framing addresses all four: an error occurred, errors can be prevented, violators should be punished, moral wrong leads to suffering. In summary, patient safety’s rise resulted from five factors: a general decrease in risk tolerance, the industrialization of healthcare, reframing harm as “error,” brief input from safety sciences holding out potential for improvement, and medicine’s effort to retain control of healthcare internally. Ironically, these factors also tended to make patient safety activity ineffective since they bounded out insights, skills, and theories from the safety sciences.