Adaptive regulation or governmentality: patient safety and the changing regulation of medicine

Studies from across the world have shown that clinical mistakes are a major threat to the safety of patient care (World Health Organisation 2004). For the National Health Service (NHS) of England and Wales it is estimated that one in ten hospital patients experience some form of error, and each year these cost the service over £2billion in remedial care (Department of Health 2000). Unsurprisingly, ‘patient safety’ is now a major international health policy priority, questioning the efficacy of existing regulatory practices and proposing a new ethos of learning. Within England and Wales, the National Patient Safety Agency (NPSA) has been created to lead policy development and champion service-wide learning, whilst throughout the NHS the National Reporting and Learning System (NRLS) has been introduced to enable this learning (NPSA 2003). This paper investigates the extent to which, in seeking to better manage the threats to patient safety, this policy agenda represents a transition in medical regulation.

Doctors' thinking about the system as a threat to patient safety

‘Systems thinking’ is an important feature of the emerging ‘patient safety’ agenda. As a key component of a ‘safety culture’, it encourages clinicians to look past individual error to recognise the latent factors that threaten safety. This paper investigates whether current medical thinking is commensurate with the idea of ‘systems thinking’ together with its implications for policy. The findings are based on qualitative semistructured interviews with specialist physicians working within one NHS District General Hospital in the English Midlands. It is shown that, rather then favouring a 'person-centred’ perspective, doctors readily identify ‘the system’ as a threat to patient safety. This is not necessarily a reflection of the prevailing safety discourse or knowledge of policy, but reflects a tacit understanding of how services are (dis)organised. This line of thinking serves to mitigate individual wrong-doing and protect professional credibility by encouraging doctors to accept and accommodate the shortcomings of the system, rather than participate in new forms of organisational learning.

Error analyses reveal contrasting deficits in “theory of mind”: neuropsychological evidence from a 3-option false belief task

Perspective taking is a crucial ability that guides our social interactions. In this study, we show how the specific patterns of errors of brain-damaged patients in perspective taking tasks can help us further understand the factors contributing to perspective taking abilities. Previous work (e.g., Samson, Apperly, Chiavarino, & Humphreys, 2004; Samson, Apperly, Kathirgamanathan, & Humphreys, 2005) distinguished two components of perspective taking: the ability to inhibit our own perspective and the ability to infer someone else’s perspective. We assessed these components using a new nonverbal false belief task which provided different response options to detect three types of response strategies that participants might be using: a complete and spared belief reasoning strategy, a reality-based response selection strategy in which participants respond from their own perspective, and a simplified mentalising strategy in which participants avoid responding from their own perspective but rely on inaccurate cues to infer the other person’s belief. One patient, with a self-perspective inhibition deficit, almost always used the reality-based response strategy; in contrast, the other patient, with a deficit in taking other perspectives, tended to use the simplified mentalising strategy without necessarily transposing her own perspective. We discuss the extent to which the pattern of performance of both patients could relate to their executive function deficit and how it can inform us on the cognitive and neural components involved in belief reasoning.