System flaws set up good people to fail. 80% of errors are system induced. People often find ways of getting around processes which seem to be unnecessary or which impede the workflow. "Normalization of deviance" describes a gradual shift in thought in which nonstandard or unacceptable behavior and standards become acceptable. People and organizations generally do not tolerate immediate, large shifts in behaviors - it would be obvious and seem ridiculous. However, we accept and barely notice incremental changes over long periods of time.
We mainly become aware of the normalization of deviance when we reach a breaking point. One graphic example of this concept was the space shuttle Challenger disaster. Accident investigators identified that the temperature on the morning of the launch was far below the known safe limit. The O-rings that failed and caused the explosion were designed to function at a temperature no lower than 59 degrees. However, over time, NASA had launched the shuttle successfully at progressively lower temperatures until eventually on the morning of the Challenger launch, the temperature on the launch pad was 29 degrees.
David Marshall, CEO of Safer Healthcare, delivers keynotes and talks on Normalization of Deviance to hospitals, boards and organizations. To learn more, contact our offices about our High Reliability Speaker Series.
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