One event, three investigations: The reproduction of a safety norm

- Three separate investigations of the same adverse event were analysed.
- Despite vastly different amount of time and resources results were strikingly similar.
- The causal factors were all constructed as deviations from a norm.
- All causal factors were found in the event's immediate temporal and spatial proximity.
- We suggest: aspects of system interaction and variability to be seen as a resource.

Following an adverse event in a Swedish university hospital in 2010, three separate investigations seeking causal factors were conducted. We here review each of the analyses to see whether they together generate the kind of epistemological pluralism that could contribute to a systemic understanding of, and learning from, the event. Our content analysis shows that, while using vastly different amounts of time and resources, all three investigations make the same analytical choice to construct the causal factors as a deviation from norm in the event's immediate temporal and spatial proximity. We recognise that this both represents a strong discourse in the community analysing adverse events and seems to fulfil certain psychological purposes. Furthermore, we suggest that thorough analysis of adverse events in healthcare need to include aspects of system interaction from the micro to the macro, cognitive work configuration and design, as well as variability as a resource to harness rather than a threat to limit and control.