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Tolerate, accommodate, innovate -- how doctors deal with the risk embedded in the medical system

Risk is an inherent element of the hospital system and the resulting dangers are often normalised by medical staff to allow them to do their job, according to research by a University of Nottingham academic.

Dr Justin Waring, Lecturer in Medical Sociology and Health Policy at the University, found that medical staff were inevitably pessimistic about the ability of their management team to understand the level of risk that doctors and nurses dealt with on a day-to-day basis. They felt that management were too far removed from the realities of clinical safety to judge best practice and that the priorities and targets that drive risk management such as cost savings and cutting waiting times diverged from those of the clinicians.

Dr Waring identified the operating theatre as a complex hub within the hospital system, which had a symbiotic relationship with other departments including surgical wards, the anaesthetic department, sterile services and lab and imaging services. Problems in the operating theatre were found to spill over into related departments, creating cascade chains of risk, which clinicians in all areas then had to deal with.

As a result, medical staff develop ritualistic behaviours that are based on shared cultural norms and expectations just to get the job done. They tolerate and endure levels of risk and sub-standard working; accommodate or accept the presence of risk by making small modifications to clinical practice; and innovate, developing new procedures to work around risk. This emphasis on coping has come to be seen as a mark of professionalism among medical staff.

The study found minimal participation in incident reporting and risk management among clinicians not because they were trying to conceal dangers and mistakes, but because coping was the mark of a professional, Dr Waring said. Risk is part of a clinicians daily life; its inherent in medical culture. Doctors can only work to minimise and control risk; they dont feel that they can eliminate it totally.

The research team identified these key themes of hospital culture during an 18-month ethnographical study in the operating department of a large teaching hospital. They carried out 300 hours of observations on site and conducted around 80 interviews with staff. The study was funded by the Department of Health.

Dr Waring has already presented his findings to Sir Liam Donaldson, Chief Medical Officer and the UKs key advisor to the government on healthcare issues and he is now contributing to a review of NHS conducted by Professor Lord Darzi, Parliamentary Under Secretary of State at the Department of Health.. This review coincides with the 60th anniversary of the NHS. A follow-up study into the way medical professionals share patient information in a bid to eliminate risk is set to begin in the New Year.

Dr Waring said: These studies reveal neglected but critical perspectives on patient safety. Critical in the sense that they are not just offering an alternative to mainstream research but also because they are of immense importance if we really want to understand and tackle the root causes of safety in healthcare.


Contact: Justin Waring
University of Nottingham

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