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Engaging doctors to reduce restraint
Published in Bernadette McSherry, Yvette Maker, Restrictive Practices in Health Care and Disability Settings, 2020
Over time, deviations from standards of practices can become normalised in health care delivery systems (Banja 2010). This is termed ‘normalisation of deviance’, meaning a process where a substandard practice becomes embedded as routine and part of acceptable practice over time. This is not related to specific maleficence of practitioners, or one-off breaches of standards that may have a range of contributing or associated factors, but rather represents unchecked drift of practice over time.
Toward a Restorative Just-Culture Approach to Medical Error
Published in Fritz Allhoff, Sandra L. Borden, Ethics and Error in Medicine, 2019
Jeremy R. Garrett, Leslie Ann McNolty
All of this is especially salient when appreciating how many errors arise from “workarounds” in the system—that is, organic and widely used, but unsanctioned, pathways that respond to inefficiencies, inconveniences, and overly demanding expectations. Consider an example from Dekker in which nurses adapt to the poor quality of medication scanners by printing out a single high-contrast barcode and using it to get reliable scans quickly, rather than struggling with technology to complete the procedure properly (Dekker 2016, 5). When such “normalization of deviance” takes hold (Kohn, Corrigan, and Donaldson 2000, 55–56), all relevant parties are using these workarounds, and all consider them as necessary for getting their jobs done. Any of those parties could have been the unfortunate person who used the workaround at the time that a unique combination of factors led to harmful error. It would be unjust for others utilizing the same, or a relevantly similar, workaround to individually blame and punish the particular person involved in that isolated incident, rather than address the larger issues that are affecting everyone and leading each of them to choose unauthorized workarounds.
Leadership
Published in Rhona Flin, George G. Youngson, Steven Yule, Enhancing Surgical Performance, 2015
Craig McIlhenny, Sarah Henrickson Parker, George G. Youngson
Surgeons need to set the standards for behaviour within their operating room and demonstrate these by adhering to good surgical practice and attention to technical skills and also by expressing positive attitudes towards wider clinical codes of good practice and by following theatre checklists and protocols (Table 7.1). The surgeon who displays these leadership skills will be rewarded with a more positive attitude towards safety within the team.5 A lack of such behaviours or, even worse, the demonstration of opposing attitudes or behaviours will provide a hidden curriculum for the rest of the team, especially surgeons in training, that positive behaviours regarding safety are not necessary for consultant surgeons. The rest of the team will quickly follow suit in letting standards slip, and very rapidly ‘normalisation of deviance’ occurs with lack of compliance with protocols and best practice becoming the norm within that operating room and being seen as acceptable behaviour.6,7 This drift towards non-adherence is especially risky because it is difficult to detect. However, this type of slow deterioration with respect to standards is important for leaders to be aware of and to monitor. Drift can be quietly insidious to an organization’s safety efforts. Instituting communication standards alongside clinical performance standards may help to mitigate some of the risk.
Content analysis of nurses’ reflections on medication errors in a regional hospital
Published in Contemporary Nurse, 2023
Anton Isaacs, Anita Raymond, Bethany Kent
Nursing shortages are a global challenge (Buchan et al., 2015; Drennan & Ross, 2019) that contributes to the ever-increasing workload on those in the workforce. However, nurses have developed a well-deserved reputation of getting on with the job without complaining even when the situation is challenging. They have built this reputation as a result of their excellent work ethic, compassion and commitment. There is however a down side to this. First proposed by Vaughan (1996), Henriksen and colleagues, argue that there exists a ‘normalization of deviance’ in healthcare settings which refers to a complaisant acceptance of shortages and adverse working conditions for nurses. If a hospital can get by with fewer nurses and other needed resources without the occurrence of serious adverse consequences, these unfavourable conditions may continue to worsen, creating thinner margins of safety, until a major adverse event occurs (Henriksen et al., 2008). This phenomenon has also been alluded to by Westbrook, Rob, et al. (2011).
Approach to analyse hazardous situations tied to recurrent production dysfunctions, by observing the work situation
Published in International Journal of Occupational Safety and Ergonomics, 2022
Generally, the protection of a system against unwanted events is done using safety barriers. According to Polet [12] and Vanderhaegen et al. [13], there are four types of barrier (Figure 1): material, symbolic, functional and immaterial (immaterial barriers are also barriers that are not physically in the work situation). These barriers can be breached. In the framework of manufacturing production systems, in order to maintain production quality, performance (production rate, number of parts per minute) and working conditions (e.g., working comfort), the operator is led to crossing these barriers when they have to leave an authorized/nominal operating space to enter a real operating space. This converges with the notion of migration, of BCTU and of reasonably predictable improper use as set out in Directive 2006/42/EC [14]. Examples of crossing these barriers are explained in Figure 1. The words violation, transgression and deviance are used to describe this behaviour [11,15–19]. As stated by Daniellou et al. [20], different factors can favour the normalization of deviance, such as strong tension between economic demands and safety requirements.
Errors and clinical supervision of intubation attempts by the inexperienced
Published in Southern African Journal of Anaesthesia and Analgesia, 2018
VM Satyapal, CC Rout, TE Sommerville
We observed supervisors intervening only when failure had occurred, seldom when equipment handling or patient positioning was incorrect. If training and evaluation are restricted to the sole outcome of placing the tube in the correct position, the structure is flawed. Obsession with successful tube placement is understandable on the part of the participant, but unnecessary on the part of the supervisor, who is immediately available to accomplish the task. While intubation itself is an appropriate end, the skills transfer process demands that the means to the end are also appropriate, which is where the supervisor should focus. Many of the ‘successful’ participants somehow managed to achieve intubation while working around errors of technique. This is highlighted by the participant who failed on two observed occasions due to poor technique, later managed to intubate successfully despite making the same errors, and later was recorded supervising other participants while still making the same errors. Thus might perseveration of error become normalisation of deviance. Whilst this seemingly had little impact in the controlled theatre environment, it could cause problems when the skill is being transferred to new unsupervised situations.