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UBC Theses and Dissertations

Creating safety in an emergency department Hunte, Garth Stephen


Hospital emergency departments (EDs) are complex, high-hazard sociotechnical systems with distinction as sites of the highest proportion of preventable patient harm. Patient safety is threatened by abbreviated and uneven care in an interrupted environment marked by uncertainty, multiple transitions over space and time, and mismatch between demand and resources. Recommendations for reporting systems, standardization, and ‘safety culture’ are at the forefront of local, national, and international strategies to improve patient safety. British Columbia is currently implementing a provincial electronic Patient Safety Learning System to enhance reporting and learning, and to facilitate a culture of safety. However, the concept of ‘safety culture’, while popular and political, remains problematic and theoretically underspecified. Moreover, there is lack of clear evidence about how emergency care providers conceptualize, make sense of, and learn from patient safety incidents, and limited evidence to guide an effective safety learning strategy for providers and staff in a busy ED. In this multi-perspective, multi-method, practice-based ethnographic inquiry conducted at an inner city, tertiary care ED, I explore how ED practitioners and staff create safety in patient care in their everyday practice. In this context, ‘safety’ is an emergent phenomenon of collective joint action, enacted dialogically by multiple actors, within a resilient system imbued with multiple social, cultural and political meanings. I claim that patient safety within an ED (and likely in other health care settings) is most effectively created through dialogic storying, resilience, and phronesis. I present an alternative account to the dominant “medical error” and bureaucratic “measure and manage” discourse, and propose an approach to creating safety, including an open communicative space to facilitate sharing stories and learning about patient safety incidents, a safety action team charged with systems analysis and empowered to enact change, and an inter-professional simulation learning environment to enhance dialogic sensemaking and innovation, that offers more to facilitate safety and resilience in everyday practice. I advocate for a pragmatic practice-based account of patient harm within an ongoing reflective conversation about safety and performance, and for foresight and resilience in anticipating and responding to the complexities of everyday emergency care.

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