Narrativizing errors of care: critical incident reporting in clinical practice.
This paper considers the rise across acute care settings in the industrialized world of techniques that encourage clinicians to record their experiences about adverse events they are personally involved in; that is, to share narratives about errors, mishaps or 'critical incidents'. The paper proposes that critical incident reporting and the 'root cause' investigations it affords, are both central to the effort to involve clinicians in managing and organizing their work, and a departure from established methods and approaches to achieve clinicians' involvement in these non-clinical domains of health care. We argue that critical incident narratives render visible details of the clinical work that have thus far only been discussed in closed, paperless meetings, and that, as narratives, they incite individuals to share personal experiences with parties previously excluded from knowledge about failure. Drawing on a study of 124 medical retrieval incident reports, the paper provides illustrations and interpretations of both the narrative and the meta-discursive dimensions of critical incident reporting. We suggest that, as a new and complex genre, critical incident reporting achieves three important objectives. First, it provides clinicians with a channel for dealing with incidents in a way that brings problems to light in a non-blaming way and that might therefore be morally satisfying and perhaps even therapeutic. Second, these narrations make available new spaces for the apprehension, identification and performance of self. Here, the incident report becomes a space where clinicians publicly perform concern about what happened. Third, incident reporting becomes the basis for radically altering the clinician-organization relationship. As a complex expression of clinical failure and its re-articulation into organizational meta-discourse, incident reporting puts doctors' selves and feelings at risk not just within the relative safety of personal or intra-professional relationships, but also in the normative context of organizational coordination, accountability, planning and management.
Centre for Clinical Governance Research, School of Public Health and Community Medicine, The University of New South Wales, Sydney 2052 NSW, Australia. r.iedema@unsw.edu.au
Rick
R
Iedema
Arthas
A
Flabouris
Susan
S
Grant
Christine
C
Jorm
D003220:Conflict, Psychological; D003422:Critical Care; D018578:Hospital-Physician Relations; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007049:Iatrogenic Disease; D019300:Medical Errors; D033262:Narration; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration*; D012308:Risk Management; D017751:Safety Management; D013597:Systems Analysis; D014342:Truth Disclosure