Constructing and re-constructing narratives of patient safety.

In the pursuit of enhanced patient safety, new forms of organisational learning have been introduced within healthcare services across the developed world. This paper examines how these systems contribute to the creation of knowledge about patient safety. The approach taken in this paper departs significantly from methods found within mainstream patient safety research. Rather than attempting to define clinical incidents through taxonomies or classifications, it considers how knowledge is socially constructed in clinical practice and through the processes of risk management. Specifically, it considers how narratives - the stories produced by staff in a large teaching hospital in the UK - about patient safety events are developed within the interactions of clinical practice, reflecting a dynamic mix of emotion and shared notions of responsibility. It then shows how these are re-produced as incident reports which transform knowledge through check-boxes and pre-defined categorisations leading to de-contextualised 'narrow narratives'. The paper then examines how these accounts are further re-produced through risk management activities as they become de-authored and re-constructed to reflect managerial assumptions about learning. Through considering how patient safety narratives emerge through these processes, the paper highlights the contribution that ethnographic research, with a particular focus on narrative construction, can make to the study of patient safety. It offers an alternative to the current orthodoxy of policy and raises questions about the capacity of such systems to shape the production of knowledge to the determinant of service improvement and to act as a mechanism of organisational power.