Unsafety

It's time we introduced a new word into our vocabulary: unsafety. Patient safety is, rightly, a top concern of clinicians and managers. The landmark report To Err is Human, for example, was subtitled Building a Safer Health System — as if generic measures to reduce human error will be followed, as night follows day, by improved patient safety.1 This is surely a no-brainer.

Not so, says a recent paper2 by a Dutch social scientist who conducted ethnographic observation in general practice, focusing mainly on the relatively high-risk setting of out-of-hours care. On the basis of many hours of observation, systematically analysed, she concluded that ‘the assumption that clinical work can be made safe by reducing errors not only is problematic, it also creates new forms of “unsafety”.’

Error is usually defined in terms such as ‘the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim’ (page 21).3 The assumption here is that clinical behaviour is the construction, followed by the execution, of a ‘plan’, and that error consists of the under-performance or misperformance of the plan.

But guess what? The empirical data from Jerak-Zuiderent's study show that in reality, general practice (and quite possibly, much of the rest of medicine too) is considerably messier than that. Uncertainty is high, hence the ‘confidence intervals’ around our predictions are necessarily wide. Often, the only way to determine what will happen next is to sit back and observe. So the judicious clinician takes it steady, reflects on emerging data, and encourages patients to do the same. How often do we record on the patient's record ‘advised return if no better in 24 hours’?

Because of this inherent and irreducible uncertainty, even when expertly trained and highly experienced (indeed, especially in these circumstances), we clinicians rarely make well-defined plans in advance. Rather, we operate in what Jerak-Zuiderent calls ‘a continuous stream of knowing and acting’, adapting the micro-detail of our behaviour on a day-by-day and even moment-by-moment basis so as to avoid the contradictions between uncertainty and safety. Safety cannot (or at least, cannot entirely) be built into a technology or a protocol on the basis of general and abstract knowledge about ‘error situations in general’. Rather, safety is an active and ongoing accomplishment, achieved on the basis of specific and emerging knowledge about ‘this situation in particular’.

Sceptical? Get hold of the paper and read the examples of ‘evidence-based safety protocols’ designed to reduce error. These protocols seem splendid in the abstract but when applied to real, concrete situations, they actually reduced the safety of real patients in unique situations — especially when implemented uncritically by staff who chose to suspend their situational judgement in favour of the rule. This is what Jerak-Ziderent calls ‘unsafety’.

So come on, funders: who will give us a research call on UNsafety?

• © British Journal of General Practice 2013