Organisational sources of safety and danger: sociological contributions tothe study of adverse events

Organisational sociology has long accepted that mistakes of all kinds are a common, even normal, part of work. Medical work may be particularly prone to error because of its complexity and technological sophistication. The re sults can be tragic for individuals and families. This paper describes four intrinsic characteristics of organisations that are relevant to the level of risk and danger in healthcare settings-namely, the division of labour an d "structural secrecy" in complex organisations; the homophily principle an d social structural barriers to communication; diffusion of responsibility and the "problem of many hands"; and environmental or other pressures leadi ng to goal displacement when organisations take their "eyes off the ball". The paper argues that each of these four intrinsic characteristics invokes specific mechanisms that increase danger in healthcare organisations but al so offer the possibility of devising strategies and behaviours to increase patient safety. Stated as hypotheses, these ideas could be tested empirical ly, thus adding to the evidence on which the avoidance of adverse events in healthcare settings is based and contributing to the development of theory in this important area.