Tatiana Pipan (ed.), Presunti Colpevoli. Dalle statistiche alla cartella clinica: indagine sugli errori in sanità, Guerini, 2014
10.6092/issn.2038-3460/17245
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Tatiana Pipan (ed.), Presumed guilty. From statistics to medical records: An investigation of medical errors, Guerini, 2014
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Book Reviews
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Barbara Czarniawska
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Tatiana Pipan (ed.), Presumed guilty. From statistics to medical records: An investigation of medical errors, Guerini, 2014
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Book Review                                                                  161
    Tatiana Pipan (ed.)
Presunti Colpevoli. Dalle statistiche alla cartella clinica: indagine sugli er-
rori in sanità [Presumed guilty. From statistics to medical records: an in-
vestigation of medical errors] Milano, Guerini, 2014, pp. 288.

Barbara Czarniawska Gothenburg Research Institute


    Tatiana Pipan’s anthology is a report from an ethnographically in-
spired study of medical errors in the Italian healthcare, conducted by a
group of researchers from University of Rome 1, La Sapienza.
    The introductory chapter by Pipan shows how controversial are data
on – presumed – medical errors, when interpreted by the Ministry of
Health, insurance companies, the Tribunal for Patients’ Rights, and the
Italian association of doctors wrongly accused of error (which uses the
abbreviation AMAMI, i.e. “Love me” in Italian). Like several authors in
this volume, Pipan used the concept of “boundary objects” (Star and
Griesemer 1989). But hers is a study that reveals the ambiguity of the
concept. Are “boundary objects” objects that are situated on a boundary,
but, although interpreted differently, unite rather than separate; or are
they objects that constitute a boundary, thus separating different actors?
To use Pipan’s vocabulary, are the statistics on medical errors liminal or
limiting objects?
    It appears that numbers, which are supposed to speak for themselves,
fail to do so. There is a true “war of data” among various actors, perhaps
because statistical data, like all numbers, are only quasi-objects, too soft,
as it were, to create and stabilize peaceful connections among combating
actors. But what type of object could play a stabilizing role? Pipan reports
that the actors involved are considering a creation of an independent ob-
servatory, a digital infrastructure common to all (not an easy task), and/or
a forum on which those battles can be fought systematically and openly.
The media are obviously playing a key role in interpreting the data; at
present in crisis, they prefer dramatic developments to peaceful resolu-
tions. Will it change when the crisis is over? Most likely – with the change
from paper media to digital media.
    Francesca D’Angeli, Ester Pedone, and Barbara Pentimalli studied the
role played by the many and varied digital medical records. A medical
record is a special type of writing, a “chain of writings done by many
hands”, and it demands a special competence from its writers. A record
can also be seen as a map of treatment; but, considering present trends in
the European health care, will it be a map of treatment or – as suggested
by Annemarie Mol (2008), who played with the semantic difference be-
tween cure and care – a map of choices made by the patients? The choic-
es made will acquire greater importance if the legal appeals by patients
become as common as they are in the USA. No doubt, however, that digi-
Book Reviews                                                 Tecnoscienza – 6 (1)

tal medical records have at least three functions: “memory”, coordination
(of cure), and, in the case of an accusation of error, legal evidence. Are
they not in conflict, at least potentially? Was it always the case, or does
the digitalization make the conflict more acute?
    The next chapter, by Barbara Mellini and Alessandra Talamo, ad-
dresses the function of actual objects, not merely such quasi-objects as
statistical data or medical records. These researchers examined nurses’
equipment, in a search for objects that help to organize treatment. It
turns out that some of those objects are formal and some have been in-
troduced informally. Furthermore, there is a difference between profes-
sional nurses, who assist patients; and professionals of nursing, who or-
ganize treatments. A variety of objects – “objects-bridges”, “dialogical
objects” and “fused objects” – helps nurses to perform those tasks and
stabilize the divisions. This further differentiation of the concept of
“boundary objects” may be helpful in the concept's continuous use, mak-
ing its ambiguity decipherable in a concrete context of application.
    An interesting analogy also exists between formal and informal objects
and the double bookkeeping routines, well known within accounting. No
wonder: after all, the risk of medical errors demands a careful accounting
of every task performed, but as in economic accounting, not everything
can be registered properly according to formal norms. Both assisting and
organizing require additional documentation, an “informal” one that
cannot be presented officially, but which is extremely useful in practice.
     In the chapter that follows, Carlo Caprari tells the fascinating story of
a checklist that travelled from the field of aerial bombarding (1935 in the
USA) on the wings of managerial fashions to the surgical theatre in a Ro-
man hospital in 2004. Yet checklists are also quasi-objects of doubtful
use. The solution conventionally applied is to improve the checklist or to
create additional checklists. Checking on all important points soon be-
comes a ritual, and the longer or more numerous the lists, the more com-
plicated the ritual. It does not reduce the actual complexity of the surgical
theater, though; indeed, it becomes theatrical in the literal sense of the
word.
    In general, instruments such as checklists, provided by risk manage-
ment – a recent managerial fashion – are perceived by the hospital per-
sonnel as “punishments and invasions”. Caprari’s interlocutors were often
evoking the contrast between “art” (of cure) and “evidence” (alluding to
another managerial fashion, that of Evidence Based Medicine). “Art” is
doing treatment; “evidence” is the production of multiple quasi-objects
that may or may not help the treatment.
    Virginia Romano’s chapter reports her direct observation of emergen-
cy services. Emergency services consist of three stages: the triage, the dis-
patch and the rescue. These three stages are documented on the emer-
gence sheet, and Romano analyzed the role it plays: is it a documentation,
a script for action, or both?
    Emergency services can be seen as the epitome of organizing actions.
Book Review                                                                 163
Triage – the assigning of degrees of urgency to wounds or illnesses – was
originally launched in the 1930s by the French military for assessing
wounds on the battlefield. It is an act of codification. Dispatch consists of
translating the code into a script for action (Latour 2011). The actual res-
cue is heavily burdened by uncertainty about the accuracy of both the
codification and the translation. Of course, organizing emergency rescue
differs from most other types of organizing on at least two dimensions:
speed and the cost of an error (that is, the volume of risk). But it is exact-
ly because of these two differences that the study of emergency services –
an extreme case of organizing – is of value in understanding organizing.
    Barbara Pentimalli’s chapter presents a fascinating case of disembed-
ding: a travel of medical records from the hospital to the Tribunal for Pa-
tients' Rights. All of a sudden, the records become like Sumerian tablets,
to be interpreted independent of the writers' intentions. Moreover, be-
cause they have been written by many hands, the records are an extraor-
dinary example of what Mikhail Bakhtin called “variegated speech”. It is
not even certain that readers at the Tribunal would understand the dia-
lects and jargons used in the clinical records, but they will certainly at-
tempt to decipher them. The resulting interpretation may or may not co-
incide with the intentions of the writers, but this is true of all texts, in-
cluding those written with numbers. Will all the parties involved in the
interpretation be willing to accept this and other conclusions drawn by
the researchers? A confrontation with the practitioners (who, hopefully,
will be interested in the book) should tell.
    The team’s explorations are characterized by a meso-perspective: in-
between the micro images of personal interactions and the abstractions of
macro-theorists. In my reading, that perspective is extremely useful for
practice and theory alike.
    As to further research, the volume contains many threads that would
be worthy of further research topics. It would be of great value if com-
parative studies were conducted in other European health systems.

References
Bakhtin, M.M. (1981) Discourse in the novel, in The dialogical imagination: Four
       essays. Austin, TX: University of Texas Press, pp. 259–422.
Latour, B. (2011) What's the story? Organizing as a mode of existence, in J.-H.
       Passoth, B. Peuker and M. Schillmeier (eds.) Agency without actors? New
       approaches to collective action, London, Routledge, pp. 163-177.




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