Taming uncertainty? Performance, personalisation and practices of patient safety in an Australian mental health service

Abstract

The patients implied by the term patient safety are most commonly lying on an operating table or in a hospital bed. They are cast as potential victims of harm resulting from their encounters with a health service, harm which is often attributed to malfunctioning systems or toxic cultures of care. Mental health patients and professionals, and the particularities of the illnesses and interventions which structure their encounters, have often been ignored in this discourse. This study is about what patient safety means from the perspective of professionals in a mental health context, where: risk type and severity are contested and unpredictable; patients are often viewed as a threat to their own safety; and the professional role in keeping patients safe extends to interest in their social and economic circumstances. Emphasis in patient safety research is often given to the causes and consequences of error and harm, but this research brings the day-to-day unfolding of professional work to the fore. This shift in perspective allows for a detailed examination of the strategies staff members use to enact safety, and a concomitant exploration of the degree to which policies and rules penetrate practice. This has been accomplished through the ethnographically-informed design of an inquiry into understandings and enactments of safe care among a multidisciplinary range of staff in a community mental health team and an acute inpatient psychiatric unit in New South Wales, Australia. In the course of daily work, these professionals are found to negotiate a tension between two versions of patient safety. In the fluidity of everyday practice, the safe patient is only ever a transient, fragile phenomenon anchored to a particular time, place, and relationship between clinician and patient. However, the expectation of policymakers, Coroners, and members of the public is that the mental health service should act as guarantor of safety. Theoretical frameworks of socio-material ontology are used to tease out the implications of these sometimes contradictory demands, and to explore the possibility of a patient safety which prioritises therapeutic impact on the patient rather than only the management of their risk.