Patient Safety and Organizational Learning

The key trope of patient safety policy is learning. With the motto of going from ‘a culture of blame to a learning culture’, the safety program introduces a ‘systemic perspective’ to facilitate openness and willingness to talk about failures, hereby making failures into a system property. Within the mainstream safety
orthodoxy the system is understood as a static and well-defined entity and the primary ‘learning model’ is to ‘fix the system’ by introducing standards, procedures and safety devices. The goal is to create a system as independent of experience and memory as possible. Drawing upon American pragmatism, situated learning theory and science and technology studies, the paper contrasts the notion of ‘systemic’ learning expressed by the safety policy program with notions of learning as a socio-materially situated practice. Based on fieldwork conducted in 2010 in a Danish university hospital, I propose that learning, and more specifically learning from critical incidents, should be understood as a
practical and experience-based activity as well as an equally individual and social achievement, which is always formed in relation to the specificities of the concrete situation. Parting from this perspective, I further indicate how safety technologies, such as root cause analysis, might bring about learning not because of but in spite of their standardized methodologies and solutions.
Hereby, the paper aims to contribute to debates within STS concerning questions of safety, risk and the relationship between standardization and flexibility in clinical practices.