TY - GEN
T1 - In the guise of safety
T2 - The cultural-cognitive ecosystem of medication errors and patient safety
AU - Lebahn-Hadidi, Malte
PY - 2022/2/8
Y1 - 2022/2/8
N2 - This thesis takes a humanities-based perspective on the widespread medication adverse events that causes much patient harm and increases costs in Danish healthcare as well as globally. The study is based on the question of why safety interventions are not being reconceptualized when they have failed to provide significant reductions in medication errors. Here, the thesis positions itself within current debates among safety researcherswho compete on two different proposals for our current predicament in healthcare. On the one hand, the paradigm of Safety-II asserts that healthcare problems stem from a reactive,prohibitive attitude to healthcare adverse events (termed a Safety-I paradigm) taken by hospitals. For the proponents of Safety-II, hospitals must psychologically shift to a proactive attitude where nurses and doctors are thought of as resources rather than liabilities. On the other hand, the paradigm of Safety-III holds that such a view focuses entirely on the human operator and that a broader systems thinking and engineering of hospital environments is required for total healthcare safety. This thesis combines aspects of both paradigms. It focuses both on psychological, experiential factors that contribute to medication errors as well as systemic factors. It does so by combining phenomenological hermeneutics with distributed cognition in an action research investigation at two Danish hospitals. Through this integrated approach, the thesis produces a situated description of cultural-cognitive ecosystem of medication errors, and it presents a concrete proposal for how to approach medication errors in the future. The thesis consists of two parts: first, four chapters that summarize the thesis approach and results and, second, four journal articles for scientific publication. In the summary chapters, it is described how the integration of phenomenological hermeneutics and distributed cognition in action research leads to a combination of qualitative methods, specifically cognitive ethnography, Cognitive Event Analysis, phenomenological interviews, and hermeneutic interpretation. The integration allows the thesis to both investigate organizational practice through the experiences of individual organization members and through descriptions of how people, artifacts, technologies, and cultures produce results together. Next, the thesis comprises four scientific articles. In the first article, the thesis investigates cultural perceptions of healthcare errors through an analysis of popular medical television dramas. It seeks to identify which messages of adverse events are taken-forgranted by the public. From this cultural view, the thesis then zooms all the way in on a single medication error in a Danish hospital in the second article. Through cognitive video ethnography, the emergence of medical error at a micro-scale, in one specific hospital department and with one specific patient, is explored. It is shown how even safe medication administration can produce risk and thus become error-prone over time. Based on both the macro-cultural and micro-cognitive understanding of medication errors, a simulation-based training course for healthcare professionals is constructed and carried out at four different Danish hospital wards. In the third article, the available evidence of the effectiveness of simulation-based team training for improving human factor skills for healthcare professionals is synthesized. The systematic review finds significant evidencethat simulation training is an effective way to improve human factor skills. In the fourth article, the application of simulation training inside the medicine rooms of hospital wards is described and evaluated. It is found that medicine administration simulation training increases awareness of interruptions of medicine administration and strengthens nurses’ strategies for handling interruptions.The thesis concludes that medication errors are hard to reduce because they stem from human, organizational and ecosystemic factors. The thesis finds two of such factors of high importance, and that is cultural and cognitive pressures on the hospital organization. On the cultural macro-scale there is a shared myth that healthcare errors are meaningful events from which healthcare professionals can learn and thereby get better at their job. The common sense is that error rates decrease over time, although this is in unrealistic idea of healthcare adverse events such as medication errors, and it can lead to a gap between what the public expects of healthcare and what hospitals can deliver. On the cognitive micro-scale inside two case hospitals, it is found that even safe medicine administration involves an increase of risks in other parts of the work because of the conflicting demands put on nurses administering medicine. This dynamic makes medicine administration prone to error over time. Thus, the hospital organization is both pressured from a public that assumes that error decreases over time and from the interactivity of everyday medicine administration that inevitably produce some medication errors due to the inherent risk of the medicine administration process.The thesis also finds that in situ simulation-based team training in general is an effective way of improving the human factor skills of healthcare professionals. Training how to handle interruptions of medicine administration through in situ simulation training improves the awareness of interruptions among participating professionals and can improve professionals’ ability to deal effectively with the conflicting demands that are the sourceof many medication errors. Overall, it is found that in situ simulation team training can be an effective way of addressing the above mentioned cultural and cognitive pressures of medication errors for the hospital organization. It is fruitful for healthcare professionals to prepare and reflect on their own practice. Without careful preparation of and reflection on medicine administration practices, the built-in risks of normal, safe medication administration go unnoticed and can incubate future error. Based on this conclusion, the thesis points towards the combination of phenomenological hermeneutics and distributed cognition as a way forward in humanities-based healthcare safety research.
AB - This thesis takes a humanities-based perspective on the widespread medication adverse events that causes much patient harm and increases costs in Danish healthcare as well as globally. The study is based on the question of why safety interventions are not being reconceptualized when they have failed to provide significant reductions in medication errors. Here, the thesis positions itself within current debates among safety researcherswho compete on two different proposals for our current predicament in healthcare. On the one hand, the paradigm of Safety-II asserts that healthcare problems stem from a reactive,prohibitive attitude to healthcare adverse events (termed a Safety-I paradigm) taken by hospitals. For the proponents of Safety-II, hospitals must psychologically shift to a proactive attitude where nurses and doctors are thought of as resources rather than liabilities. On the other hand, the paradigm of Safety-III holds that such a view focuses entirely on the human operator and that a broader systems thinking and engineering of hospital environments is required for total healthcare safety. This thesis combines aspects of both paradigms. It focuses both on psychological, experiential factors that contribute to medication errors as well as systemic factors. It does so by combining phenomenological hermeneutics with distributed cognition in an action research investigation at two Danish hospitals. Through this integrated approach, the thesis produces a situated description of cultural-cognitive ecosystem of medication errors, and it presents a concrete proposal for how to approach medication errors in the future. The thesis consists of two parts: first, four chapters that summarize the thesis approach and results and, second, four journal articles for scientific publication. In the summary chapters, it is described how the integration of phenomenological hermeneutics and distributed cognition in action research leads to a combination of qualitative methods, specifically cognitive ethnography, Cognitive Event Analysis, phenomenological interviews, and hermeneutic interpretation. The integration allows the thesis to both investigate organizational practice through the experiences of individual organization members and through descriptions of how people, artifacts, technologies, and cultures produce results together. Next, the thesis comprises four scientific articles. In the first article, the thesis investigates cultural perceptions of healthcare errors through an analysis of popular medical television dramas. It seeks to identify which messages of adverse events are taken-forgranted by the public. From this cultural view, the thesis then zooms all the way in on a single medication error in a Danish hospital in the second article. Through cognitive video ethnography, the emergence of medical error at a micro-scale, in one specific hospital department and with one specific patient, is explored. It is shown how even safe medication administration can produce risk and thus become error-prone over time. Based on both the macro-cultural and micro-cognitive understanding of medication errors, a simulation-based training course for healthcare professionals is constructed and carried out at four different Danish hospital wards. In the third article, the available evidence of the effectiveness of simulation-based team training for improving human factor skills for healthcare professionals is synthesized. The systematic review finds significant evidencethat simulation training is an effective way to improve human factor skills. In the fourth article, the application of simulation training inside the medicine rooms of hospital wards is described and evaluated. It is found that medicine administration simulation training increases awareness of interruptions of medicine administration and strengthens nurses’ strategies for handling interruptions.The thesis concludes that medication errors are hard to reduce because they stem from human, organizational and ecosystemic factors. The thesis finds two of such factors of high importance, and that is cultural and cognitive pressures on the hospital organization. On the cultural macro-scale there is a shared myth that healthcare errors are meaningful events from which healthcare professionals can learn and thereby get better at their job. The common sense is that error rates decrease over time, although this is in unrealistic idea of healthcare adverse events such as medication errors, and it can lead to a gap between what the public expects of healthcare and what hospitals can deliver. On the cognitive micro-scale inside two case hospitals, it is found that even safe medicine administration involves an increase of risks in other parts of the work because of the conflicting demands put on nurses administering medicine. This dynamic makes medicine administration prone to error over time. Thus, the hospital organization is both pressured from a public that assumes that error decreases over time and from the interactivity of everyday medicine administration that inevitably produce some medication errors due to the inherent risk of the medicine administration process.The thesis also finds that in situ simulation-based team training in general is an effective way of improving the human factor skills of healthcare professionals. Training how to handle interruptions of medicine administration through in situ simulation training improves the awareness of interruptions among participating professionals and can improve professionals’ ability to deal effectively with the conflicting demands that are the sourceof many medication errors. Overall, it is found that in situ simulation team training can be an effective way of addressing the above mentioned cultural and cognitive pressures of medication errors for the hospital organization. It is fruitful for healthcare professionals to prepare and reflect on their own practice. Without careful preparation of and reflection on medicine administration practices, the built-in risks of normal, safe medication administration go unnoticed and can incubate future error. Based on this conclusion, the thesis points towards the combination of phenomenological hermeneutics and distributed cognition as a way forward in humanities-based healthcare safety research.
U2 - 10.21996/jrx7-5a84
DO - 10.21996/jrx7-5a84
M3 - Ph.D. thesis
PB - Syddansk Universitet. Det Humanistiske Fakultet
CY - Odense
ER -