Exploring structure, agency and performance variability in everyday safety: An ethnographic study of practices around infusion devices using distributed cognition

Abstract

© 2019 The Authors Objectives: Infusion safety is a recognised concern internationally. While few observational studies explore the causes of the errors that occur, even fewer describe how safety is maintained in routine practice. We sought to understand safety around infusion devices. Methods: An ethnographic study of infusion device use was conducted on a haematology ward. This included observations of 51 infusions, plus their preparation where possible, during 120 h of ward observation over 11 days. Field notes were transcribed and analysed using deductive coding informed by distributed cognition. A further inductive thematic analysis highlighted new themes for making sense of the data. Results: The distributed cognition analysis highlighted how infusion treatment was affected by interactions distributed across artefacts, tasks, social networks, physical space and time. These interactions occurred close to and away from the infusion: at micro, meso and macro levels according to distance from the actual process. The inductive analysis highlighted three new interdependent themes that account for how safety is constructed and compromised: structure, agency and performance variability. Discussion and conclusion: Safety is constructed through the co-evolution of sociotechnical structure and agency whereby structure shapes and influences people's behaviour and people reproduce and create structures. Everyday performance variability emerges from these interactions, including deviations in processes and outcomes (e.g. incidents, near misses and opportunities). Studies of everyday safety can explore interactions between four points of a sociotechnical structuration model: structure, agency, and satisfactory and unsatisfactory performance.