Defensive decoupling: Tensions and contradictions in a US surgical safety intervention

Physicians have the professional mandate to lead patient safety reform in their local health settings. Yet, research finds physicians may seek to disrupt safety reform and decouple the initiative from clinical work routines. This form of ritualism is attributed to jurisdictional disputes and threats to physician authority between physicians and other frontline occupations. In this article, we set out to examine organizational and professional factors driving ritualism over the course of a three-year safety intervention (2013-2015) in two US surgical departments. The intervention design included a longitudinal qualitative study of project processes and outcomes, interviewing physicians, nurses and technicians, and administrators about their experiences of the reform. A key finding from the case comparison was physicians may not always perceive quality improvement to be aligned with their professional mission. We introduce the term defensive decoupling, an extension of defensive medicine from doctor-patient relationships to patient safety reform. In response to threats from regulatory sanctions and risk of medical liability, surgeons retreat from patient safety reform. Our findings highlight the unique tensions faced by community hospitals in medically underserved settings, where safety reform is perceived by physicians as a form of social control and undermined trust in the profession.