Accountability, organisational learning and risks to patient safety in England: Conflict or compromise?

Health, Risk and Society

Volumn 13, Issue 4, 2011, Pages 327-346

  Dodds, Anneliese ^a   Kodate, Naonori ^b  

^a ASTON UNIVERSITY   (United Kingdom)

^b KING'S COLLEGE LONDON   (United Kingdom)

Author keywords

Accountability; Organisational learning; Patient safety; Risk; Risk regulation

Indexed keywords

ARTICLE; HEALTH CARE ORGANIZATION; HEALTH CARE POLICY; HEALTH CARE SYSTEM; HEALTH SERVICE; HUMAN; PATIENT SAFETY; RISK FACTOR; UNITED KINGDOM;

EID: 79957862086     PISSN: 13698575     EISSN: 14698331     Source Type: Journal    
DOI: 10.1080/13698575.2011.575454     Document Type: Article

References (96)

1. Ackroyd, S., Kirkpatrick, I., and Walker, R.M., 2007. Public management reform in the UK and its consequences for professional organisation: A comparative analysis. Public Administration, 85 (1), 9-26.
2. Allsop, J., 2002. Regulation and the medical profession. In: J. Allsop and M. Saks, eds. Regulating the health professionals. London: Sage.
3. Allsop, J. and Saks, M., 2002. Introduction: The regulation of health professions. In: J. Allsop and M. Saks, eds. Regulating the health professionals. London: Sage.
4. Ayres, I. and Braithwaite, J., 1992. Responsive regulation: Transcending the deregulation debate. Oxford: Oxford University Press.
5. Barach, P. and Small, S.D., 2000. How the NHS can improve safety and learning, editorial. British Medical Journal, 320, 1683-1684.
6. Bartle, I. and Vass, P., 2007. Self-regulation within the regulatory state: Towards a new regulatory paradigm? Public Administration, 85 (4), 885-905.
7. Baum, M., 2004. Making amends misses the point. British Medical Journal, 328, 7436.
8. Bevan, G. and Cornwell, J., 2006. Structure and logic of regulation and governance of quality of health care: Was OFSTED a model for the Commission for Health Improvement? Health Economics, Policy and Law, 1 (4), 343-370.
9. Bosk, C., 2005. Continuity and change in the study of medical error: The culture of safety on the shop floor. Paper no. 20, Occasional Paper, Institute for Advanced Study School of Social Science, Princeton.
10. Braithwaite, J., 1985. To punish or to persuade: Enforcement of coal mine safety. Albany: State University of New York Press.
11. Brown, P., 2008. Trusting in the New NHS: Instrumental versus communicative action. Sociology of Health and Illness, 30 (3), 349-363.
12. Chief Medical Officer, 2006. Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients. London: Department of Health, HMSO.
13. Cook, G.A., 2000. Clinical incidents and risk management - a public health issue. Journal of Epidemiology and Community Health, 54, 242-243.
14. Coombes, R., 2005. NHS errors led to more than 800 deaths. British Medical Journal, 331, 7511.
15. Currie, G. and Suhomlinova, O., 2006. The impact of institutional forces upon knowledge sharing in the UK NHS: The triumph of professional power and the inconsistency of policy. Public Administration, 84 (1), 1-30.
16. Currie, G., Waring, J., and Finn, R., 2008. The limits of knowledge management for UK public services modernization: The case of patient safety and service quality. Public Administration, 86 (2), 363-385.
17. Darzi, A., 2008. High quality care for all: NHS next stage review final report. London: HMSO.
18. Day, M., 2007. Doctors attack Gordon Brown's plans to regulate medical profession. British Medical Journal, 335, 113.
19. Day, P. and Klein, R., 2004. The NHS improvers: A study of the commission for health improvement. London: King's Fund.
20. Dekke, S., 2007. Just culture: Balancing safety and accountability. Aldershot: Ashgate.
21. Department of Health, 1998. A first class service: Quality in the new NHS. London: HMSO.
22. Department of Health, 1999. Supporting doctors, protecting patients: A consultation document. London: HMSO.
23. Department of Health, 2000. An organization with a memory. London: HMSO.
24. DiMaggio, P., 1991. Constructing an organizational field as a professional project: US art museums, 1920-1940. In:W.W. Powell and P.J. DiMaggio, eds. The new institutionalism in organizational analysis. Chicago: University of Chicago Press.
25. Donaldson, L., 2006. Safety first: A report for patients, clinicians and healthcare managers. London: HMSO.
26. Donaldson, L.J., 2000. An organisation with a memory. London: HMSO.
27. Dyer, O., 2007. Simple precautionary measures can reduce numbers of falls in hospital. British Medical Journal, 334, 7591.
28. Ehrich, K., 2006. Telling cultures: 'Cultural' issues for staff reporting concerns about colleagues in the UK National Health Service. Sociology of Health & Illness, 28 (7), 903-926.
29. Elston, M.A., 1991. The politics of professional power: Medicine in a changing health service. In: J. Gabe, M. Calnan, and M. Bury, eds. The sociology of the health service. London: Routledge.
30. Ferner, R. and McDowell, S., 2005. Letter: Criminal proceedings will hamper calls for open culture. British Medical Journal, 331, 1272.
31. Flynn, R., 2002. Clinical governance and governmentality. Health, Risk & Society, 4 (2), 155-173.
32. Friedland, R. and Alford, R.R., 1991. Bringing society back in: Symbols, practices, and institutional contradictions. In: W.W. Powell and P.J. DiMaggio, eds. The new institutionalism in organizational analysis. Chicago: University of Chicago Press.
33. Freidson, E., 1970. The profession of medicine. New York: Harper Row.
34. Fulop, N., Chamberlain, J., Baeza, J., Humphrey, C., Magnusson, C., and Rothstein, H., 2008. Governing for patient safety, working paper, NIHR King's Patient Safety and Service Quality Centre (PSSQ) Organisational Governance Programme. London: King's College London.
35. Glennerster, H., 1994. Implementing GP fundholding: Wild card or winning hand? London: Open University Press.
36. GMC, 2006. Press release: Members of the public help shape the way doctors are regulated, 19th May. London: GMC.
37. Gornall, J., 2006. Professional regulation: the path to safer patients. British Medical Journal, 333, 7574.
38. Ham, C. and McIver, S., 2000. Contested decisions: Priority setting in the NHS. London: King's Fund.
39. Harrison, S. and Ahmad, W.I.U., 2000. Medical autonomy and the UK state 1975 to 2025. Sociology, 34 (1), 129-146.
40. Harrison, S., Hunter, D.H., and Pollitt, C., 1990. The dynamics of British health policy. London: Unwin Hyman.
41. Hawkins, K., 1984. Environment and enforcement: Regulation and the social definition of pollution. Oxford: Clarendon.
42. Helgøy, I. and Homme, A., 2006. Policy tools and institutional change: Comparing education policies in Norway, Sweden and England. Journal of Public Policy, 26 (2), 141-165.
43. Hitchen, L., 2007. Collaboration between regulators and industry on design of drugs could reduce errors. British Medical Journal, 335, 743.
44. Hood, C., Rothstein, H., and Baldwin, R., 2001. The government of risk: Understanding risk regulation regimes. Oxford: Oxford University Press.
45. Hood, C.C., Jones, D.K.C., Pidgeon, N.F., Turner, B.A., Gibson, R., and contributors, 1992. Risk management. In Risk: Analysis, perception and management, Report of a Royal Society Study Group. London: The Royal Society.
46. Hopkins, A., 2001. Lessons from Longford: The Esso gas plant explosion. Sydney: CCH.
47. Horlick-Jones, T., 2005. On 'risk work': professional discourse, accountability, and everyday action. Health, Risk & Society, 7 (3), 293-307.
48. IOM Committee on Quality of Health Care in America, 2000. To err is human: Building a safer health system. Washington: National Academy Press.
49. Jayasuriya, J.P. and Anandaciva, S., 1995. Compliance with an incident report scheme in anaesthesia. Anaesthesia, 50, 846-849.
50. Johnson, C.W., 2003. Failure in safety-critical systems: A handbook of accident and incident reporting. Glasgow: University of Glasgow Press.
51. Kaye, R.P., 2006. Regulated (self-)regulation: a new paradigm for controlling the professions? Public Policy and Administration, 21, 105-119.
52. Kingston, M.J., Evans, S.M., Smith, B.J., and Berry, J.G., 2004. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Medical Journal of Australia, 181 (1), 36-39.
53. Kitchener, M., 2002. Mobilizing the logic of managerialism in professional fields: The case of academic health center mergers. Organization Studies, 23 (3), 391-420.
54. Klein, R., 2001. The new politics of the NHS. Harlow: Pearson.
55. Laurance, J., 1998. How can we watch the doctors? The Independent, 31 May, p. 6.
56. Leape, L., 1994. Error in medicine. Journal of the American Medical Association, 272, 1851-1857.
57. Leape, L., 1999. Error in medicine. In: M. Rosenthal, L. Mulcahy, and S. Lloyd-Bostock, eds. Medical mishaps. Buckingham: Open University Press.
58. Lloyd-Bostock, S. and Hutter, B.M., 2008. Reforming regulation of the medical profession: The risks of risk-based approaches. Health, Risk & Society, 10 (1), 69-83.
59. Lipsky, M., 1983. Street level bureaucracy: Dilemmas of the individual in public services. New York: Russell Sage Foundation.
60. Macrae, C., 2008. Learning from patient safety incidents: Creating participative risk regulation in healthcare. Health, Risk & Society, 10 (1), 53-67.
61. McDonald, R., Waring, J.J., and Harrison, S., 2005. 'Balancing risk, that is my life': The politics of risk in a hospital operating theatre department. Health, Risk & Society, 7 (4), 397-411.
62. Moran, M. and Wood, B., 1993. States, regulation and the medical profession. Buckingham: Open University Press.
63. Mulcahy, L. and Lloyd-Bostock, S., 1992. Complaining - what's the use? In: R. Dingwall and P. Fenn, eds. Quality and regulation in health care: International experiences. London: Routledge.
64. Mullins, D., 2006. Competing institutional logics? Local accountability and scale and efficiency in an expanding non-profit housing sector. Public Policy and Administration, 21 (3), 6-24.
65. NHSLA, 2008. NHSLA risk management standards for acute Trusts, April. London: NHSLA.
66. NPSA, undated. Incident decision tree. Available from: http://report.npsa.nhs.uk/idt2/(s(wzxwo02h3imdji455sy4g055))/index.aspx [Accessed May 2011].
67. Orbe, M.P. and King, G., 2000. Negotiating the tension between policy and reality: Exploring nurses' communication about organizational wrongdoing. Health Communication, 12, 41-61.
68. Power, M., 2004. The risk management of everything: Rethinking the politics of uncertainty. Available from: http://www.demos.co.uk/files/riskmanagementofeverything.pdf [Accessed 1 April 2011].
69. Price, D., 2002. Legal aspects of the regulation of the health professions. In: J. Allsop and M. Saks, eds. Regulating the health professionals. London: Sage.
70. Reason, J., 1997. Managing the risks of organizational accidents. Aldershot: Ashgate.
71. Reay, T. and Hinings, C.R., 2005. The recomposition of an organizational field: Health care in Alberta. Organization Studies, 26 (3), 351-384.
72. Redfern, M., Keeling, J.W., and Powell, E., 2001. The Royal Liverpool Children's inquiry report. London: Her Majesty's Stationery Office.
73. Rose, N. and Miller, P., 1992. Political power beyond the state: Problematics of government. British Journal of Sociology, 43, 173-205.
74. Rothstein, H., Huber, M., and Gaskell, G., 2006. A theory of risk colonisation: The spiralling regulatory logics of societal and institutional risk. Economy and Society, 35 (1), 91-112.
75. Sagan, S., 1993. The limits of safety: Organizations, accidents, and nuclear weapons. Princeton, NJ: Princeton University Press.
76. Salter, B., 1998. The politics of change in the health service. Basingstoke: Macmillan.
77. Salter, B., 2000. Change in the governance of medicine: the politics of selfregulation. In: D. Gladstone, ed. Regulating doctors. London: Institute for the Study of Civil Society.
78. Saltman, R.B. and Otter, C.v., 1995. Implementing planned markets in health care: Balancing social and economic responsibility. Buckingham: Open University Press.
79. Schwartz, R., 2000. School accountability - an elusive policy solution: The Israeli experience in comparative perspective. Journal of Public Policy, 20 (3), 195-218.
80. Scott, C., 2000. Accountability in the regulatory state. Journal of Law and Society, 27 (1), 38-60.
81. Scott, W.R., Ruef, M., Mendel, P.J., and Caronna, C.A., 2000. Institutional change and healthcare organizations: From professional dominance to managed care. Chicago: University of Chicago Press.
82. Sheaff, R. and Pilgrim, D., 2006. Can learning organizations survive in the newer NHS? Implementation Science, 1 (27), 1-11.
83. Smith, D., 2002. Not by error, but by design - Harold Shipman and the regulatory crisis for health care. Public Policy and Administration, 17 (4), 55-74.
84. Smith, R., 1998. All changed, changed utterly. British Medical Journal, 316, 1917-1918.
85. Spencer, L., Ritchie, J., Lewis, J., and Dillon, L., 2003. Quality in qualitative evaluation: A framework for assessing research evidence, government chief social researcher's office. London: Cabinet Office.
86. Thornton, P.H., 2002. The rise of the corporation in a craft industry: Conflict and conformity in institutional logics. Academy of Management Journal, 45 (1), 85-101.
87. Thornton, P.H., Jones, C., and Kury, K., 2005. Institutional logics and institutional change in organizations: Transformation in accounting, architecture, and publishing. Research in the Sociology of Organizations, 23, 125-170.
88. Tuohy, C.J., 1999. Accidental logics: The dynamics of change in the health care arena in the United States, Britain, and Canada. Oxford: Oxford University Press.
89. Turner, B.S., 2001. Risks, rights and regulation: An overview. Health, risk & society, 3 (1), 9-18.
90. Vincent, C., 2006. Patient safety. Edinburgh: Elsevier.
91. Vincent, C., 2007. Editorial: incident reporting and patient safety. British Medical Journal, 334, 51.
92. Vincent, C., Stanhope, N., and Crowley-Murphy, M., 1999. Reasons for not reporting adverse incidents: An empirical study. Journal of Evaluation in Clinical Practice, 5 (1), 13-21.
93. Walsh, P., 2003. We must accept that health care is a risky business. British Medical Journal, 326, 7402.
94. Waring, J., 2004. A qualitative study of the intra-hospital variations in incident reporting. International Journal for Quality in Health Care, 16 (5), 347-352.
95. Waring, J., 2005. Beyond blame: The cultural barriers to medical incident reporting. Social Science and Medicine, 60 (9), 1927-1935.
96. Waring, J., 2007. Adaptive regulation or governmentality: Patient safety and the changing regulation of medicine. Sociology of Health and Illness, 29 (2), 163-179