Continuity and Change in the Study of Medical Erro

ContinuityandChangeintheStudyofMedicalErrorTheCultureofSafetyontheShopFloorFEBRUARY2005,PAPERNUMBER20CharlesL.Bosk©UnpublishedbyCharlesL.BoskTheOccasionalPapersoftheSchoolofSocialScienceareversionsoftalksgivenattheSchool’sweeklyThursdaySeminar.Attheseseminars,Memberspresentwork-in-progressandthentakequestions.Thereisoftenlivelyconversationanddebate,someofwhichwillbeincludedwiththepapers.Wehavechosenpaperswethoughtwouldbeofinteresttoabroadaudience.Ouraimistocapturesomepartofthecross-disciplinaryconversationsthatarethemarkoftheSchool’sprograms.Whilemembersaredrawnfromspecificdisciplinesofthesocialsciences—anthropology,economics,sociologyandpoliticalscience—aswellashistory,philosophy,literatureandlaw,theSchoolencouragesnewapproachesthatarisefromexposuretodifferentformsofinterpretation.Thepapersinthisseriesdifferwidelyintheirtopics,methods,anddisciplines.Yettheyconcurinabroadlyhumanisticattempttounder-standhow,andunderwhatconditions,theconceptsthatorderexperienceindifferentculturesandsocietiesareproduced,andhowtheychange.CharlesBoskisProfessorofSociologyandGraduateGroupChairofSociologyattheUniversityofPennsylvania,whereheisalsoaSeniorFellowoftheCenterforBioethics.ProfessorBoskwasaMemberoftheSchoolofSocialScienceduringthethirdyearofitsfocusonethics,whenattentionturnedtobio-medicalethics.Theemergence,inthepasttwodecades,ofaspecialtysuchasbioethicssignalsaturntowardanalyticalissueswhosequestionshavelesstodowiththemoralstatusofthesocialsciencesthanwiththemoralissuesthatarisewithinmedicineconsideredasasocialpractice.Membersduringthisyearexaminedthewaysinwhichmedicaltechnologies(drugs,procedures,diagnostics,genetictestingandengineering,surgeries)havechangedorerodedtheboundariesbetweenpublicandprivate,andsoraisednewdilemmasforthelaw,publicpolicy,andindividualrights.CharlesBosk’sprojecttakesupthisemergenceofthenewprofessionof“ethicist.”HearguesthatifeverymajorinstitutionaldomaininAmericansocietyhasundergoneacrisisoftrust,responsibility,authority,andethics,onlyinmedicinehastheresponsebeentocreateanewhybridspecialtytorestoreconfidence.Bosk’sinterestsareasmuchintheperspectiveofthetheorizationofethicsastheyarethespecificcontents.Ratherthanbeginningfrompara-digmsofappliedethics,Boskmakesuseofthemoreethnographictoolofthecasestudy.Inhisfirstbook,ForgiveandRemember(UniversityofChicagoPress,2ndedition2003),hecarefullyobservedthetrainingandlivesofyoungsurgeons.Hissecondbook,AllGod’sMistakes:GeneticCounselinginaPediatricHospital,istheresultofthreeyearsspentasa“guest”witnessobservingateamofgeneticcounselorsinanunidentifiedchildren’shospital.Avolumeofessays,WhatWouldYouDo?TheCollisionofEthicsandEthnography,issched-uledforpublicationbytheUniversityofChicagoPressinthefallof2005.Thenewprojectengagesaseriesofcasestudiestounderstandtheemergenceoftheethicist.TheyserveasanentrancewedgeintothequestionofhowmoralauthorityisconstructedandlegitimatedinAmericansociety,andhowthatauthorityinfluencesthechoiceofwhichissuesareputonthepublicagenda,andwhichsolutionsreceiveconsiderationas“reasonable.”ContinuityandChangeintheStudyofMedicalError:TheCultureofSafetyontheShopFloorWithitsreport,ToErrisHuman:BuildingaSaferHealthSystem(Kohn,Corrigan,andDonaldson2000),theInstituteofMedicine’sCommitteeontheQualityofHealthCareinAmericaperformedacommendablepublicservice.Thereportdramatizedtheextentofahithertounappreciatedpublicproblem—harmtopatientsbecauseofmedicalerror—presentedadiagnosisthatlocatedtheprobleminthefailingsofsystemsratherthanindividuals,andforwardedasetoftreatmentrecommendations.1Thereport’srecommen-dationscompriseatriadfamiliartothosewhostudysafetyandpost-hocaccountsofaccidents:trainingtoimprovetheperformanceofpersonnel,newtechnologiestoimprovetheperformanceofthefalliblehumanoperators,andnewprocedurestoimprovethefunc-tioningofthesystem(CookandWoods1994).Thesechanges,ifimplemented,willbringtomedicineboththephilosophyandworkroutinesof“totalqualityimprovement”sofaraspatientsafetyisconcerned.2TheInstituteofMedicinereportsetsforitselftheoperationalgoalofcuttinginhalftheamountofmedicalerroroverthenextfiveyears.OnestrikingfeatureoftheIOMreportisthedegreetowhichitapplies,andperhapsmisapplies,onetraditionofthehumansciencesforstudyingerrorsandmistakeswhileentirelyignoringasecondapproachthathasbeenusedtounderstandthosesamephenom-enon.Theapproachthatthereportembracesisnormalaccidenttheory,ablendoforganiza-tionaltheory,cognitivepsychology,andhumanfactorsengineering(see,forexample,Perrow1984andReason1990and1997).Thistheoryholdsthatmoderntechnologicalsystemsare“error-prone”andthatweshouldthinkofcertaincatastrophes,ofwhichthemostdramaticexamplewouldbemishapsatnuclearpowerplants,as“normalaccidents.”Inthisview,accidentsandmistakes,withalltheirbalefulconsequences,arenotproducedbyindividualhumanfailings—whatCharlesPerrow,aleadingproponentofthisapproach,calls“ubiqui-tousoperatorerror.”3Rather,certainaccidentsandcatastrophesareaninevitableresultoffeaturesembeddedintheorganizationofmanyenterprisesofthemodernworld.Thetwofeaturesmostimportanttotheproductionofnormalacciden