The dark side of standardisation: When is it safer to ‘work around’ a protocol?

For many years standardisation has been relied upon to improve patient safety through reducing variation in care processes. Despite this approach being widely adopted across healthcare systems, safety remains a concern. Recently, there have been developments in the field of patient safety theory that question if standardisation is the panacea for healthcare improvement. ‘Safety II’ is a theory which views healthcare as a complex system and regards safety as the ability to succeed within varying conditions. At the heart of this theory lies the assumption that variation is not inherently risky, and that resilient systems actually rely on the ability of individuals, teams, and organisations to adapt their actions in response to changing work environments. Yet little is known about what is achieved for safety when healthcare staff adapt and work around the rules put in place to create safety. Accordingly, the overarching aim of this doctoral research was to explore whether safety standard workarounds (SSWAs) can be used to support safety as part of an active risk management strategy. Using an exploratory approach this aim was addressed by four novel objectives. The first objective explored the empirical literature to understand what is known about SSWAs in healthcare. The review found SSWAs are prolific but emphasised the implications of what workarounds achieve for safety is unclear. The second objective used an exemplar practice, to explore what workarounds look like within different healthcare settings. Objective three, investigated the similarities and differences in the enactment of SSWAs in differing settings and explored what workarounds achieve for safety. Objective four, examined multi-level stakeholder perceptions of SSWAs and explored the potential for operationalising the safer use of workarounds in practice and policy. The research in this thesis highlights that SSWAs can sometimes enhance safety. This has implications for healthcare practice, policy, and future research.