The challenge of patient safety and the remaking of American medicine

This dissertation accounts for the 'patient safety challenge,' which developed over the course of 1990s, gained prominence in the early 2000s, and now occupies a significant place in healthcare reform. Positioning medical error as a significant, wide-ranging, and entrenched problem in need of attention, the patient safety challenge is a reform discourse. Patient safety reformers challenge the healthcare industry to take action to better manage medical error, and in so doing call for a major transformation in the structure of care delivery. Charting major aspects of patient safety reform discourse, this dissertation addresses three overarching questions. First, what constitutes patient safety discourse and who are the leading advocates for patient safety reform? Next, what are advocates, and their associated discourse, attempting to change about understandings of medical error specifically, and about the organization and delivery of healthcare more generally? Finally, what are the consequences of patient safety advocacy for the medical profession and for healthcare reform? In seeking to reconstitute the medical profession with an ethos of shared responsibility and collective improvement, patient safety advocates attempt to remake the profession by redefining its culture and conduct. This dissertation examines three major aspects of patient safety discourse: how the concept of medical error has become an object of research and target for advocacy, how patient stories of medical error transform both patients and providers, and how leading advocates and organizations attempt to change notions of culture and responsibility in the organization of healthcare work. These dimensions contribute to changes in the medical profession's political role in healthcare reform, in the wake of recent comprehensive legislation. Federal reform efforts call for a significant restructuring of care delivery, influenced by a rationality of patient safety that constructs medical error as a preventable risk, asserts patients as partners in error prevention, and makes safety culture a central organizational goal. With high stakes in the shape that the US healthcare system takes over the next decade, the medical profession has been challenged, by a discourse of patient safety that the Federal government now also promotes, to join in efforts at remaking American medicin