The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

Richard C. Prielipp; Maria Magro; Robert C. Morell; Sorin J. Brull

Commentary

The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

October 20, 2010

Prielipp RC, Magro M, Morell RC, et al. AANA J. 2010;78(4):284-7.

View more articles from the same authors.

This commentary describes normalization of deviance and uses examples to illustrate how this problem could appear in anesthesia practice.

PubMed citation

Available at

Related Resources From the Same Author(s)

Survey of the national drug shortage effect on anesthesia and patient safety: a patient perspective.

August 12, 2015

Increasing patient safety and surgical team communication by using a count/time out board.

October 20, 2010

Surgical count practice variability and the potential for retained surgical items.

February 22, 2012

Infection prevention in the operating room anesthesia work area.

January 30, 2019

World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for a Safe Practice of Anesthesia.

May 23, 2018

The role of automation in complex system failures.

May 11, 2005

Root causes of errors in a simulated prehospital pediatric emergency.

February 29, 2012

Engaging the patient and family in the surgical safety process utilizing SafeStart.

August 28, 2019

Developing standardized "receiver-driven" handoffs between referring providers and the emergency department: results of a multidisciplinary needs assessment.

December 5, 2018

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events.

June 6, 2007

Organizational and cultural changes for providing safe patient care.

August 3, 2005

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

June 11, 2014

Monitoring patient safety in health care: building the case for surrogate measures.

February 8, 2006

Staying safe: simple tools for safe surgery.

April 25, 2007

The Preventable Harm Index: an effective motivator to facilitate the drive to zero.

October 27, 2010

Winning the battle for standardization.

November 7, 2007

Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.

April 25, 2007

Development and validation of a tool to improve paediatric referral/consultation communication.

August 3, 2011

Probabilistic risk assessment of accidental ABO-incompatible thoracic organ transplantation before and after 2003.

February 6, 2008

A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality.

August 21, 2013

Differentiating between detrimental and beneficial interruptions: a mixed-methods study.

November 9, 2016

Can aviation-based team training elicit sustainable behavioral change?

January 6, 2010

Using computerized virtual cases to explore diagnostic error in practicing physicians.

February 13, 2019

Undertriage of elderly trauma patients to state-designated trauma centers.

October 8, 2008

A system analysis of a suboptimal surgical experience.

February 4, 2009

February 2, 2022

Resilience and resilience engineering in health care.

July 30, 2014

Physicians' beliefs about using EMR and CPOE: in pursuit of a contextualized understanding of health IT use behavior.

February 3, 2010

Cognitive performance-altering effects of electronic medical records: an application of the human factors paradigm for patient safety.

January 30, 2005

What stands in the way of technology-mediated patient safety improvements? A study of facilitators and barriers to physicians' use of electronic health records.

December 21, 2011

Supporting carers to improve patient safety and maintain their well-being in transitions from mental health hospitals to the community: a prioritisation nominal group technique.

August 16, 2023

Anticipating patient safety events in psychiatric care.

February 7, 2024

Effectiveness of pharmacist intervention to reduce medication errors and health-care resources utilization after transitions of care: a meta-analysis of randomized controlled trials.

July 19, 2017

A typology of electronic health record workarounds in small-to-medium size primary care practices.

August 21, 2013

Using a network organisational architecture to support the development of Learning Healthcare Systems.

February 21, 2018

Honesty and transparency, indispensable to the clinical mission--Parts I-III.

December 15, 2021

Studying the technical work of emergency care.

October 31, 2007

Nursing interruptions in a trauma intensive care unit: a prospective observational study.

May 3, 2017

Use of cascading A3s to drive systemwide improvement.

August 2, 2017

Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.

January 27, 2016

Implementing a bar-code medication administration system.

January 21, 2009

Patient perspectives on test result communication in primary care: a qualitative study.

April 29, 2015

Clinical criteria to screen for inpatient diagnostic errors: a scoping review.

March 25, 2015

Another look at medical error.

March 6, 2005

Increasing demands for quality measurement.

November 27, 2013

Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system.

December 14, 2005

Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.

May 27, 2009

High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.

March 21, 2012

National Quality Forum 30 safe practices: priority and progress in Iowa hospitals.

April 26, 2006

Association of default electronic medical record settings with health care professional patterns of opioid prescribing in emergency departments: A randomized quality improvement study

February 12, 2020

Clinical decision support for early recognition of sepsis.

April 20, 2016

Routine failures in the process for blood testing and the communication of results to patients in primary care in the UK: a qualitative exploration of patient and provider perspectives.

September 9, 2015

Test result communication in primary care: a survey of current practice.

August 19, 2015

The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.

June 27, 2018

Defining patient safety events in inpatient psychiatry.

August 22, 2018

Interruptions in the wild: development of a sociotechnical systems model of interruptions in the emergency department through a systematic review.

October 28, 2015

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Evaluating service delivery interventions to enhance patient safety.

January 14, 2009

Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care.

July 25, 2012

Real-time automated paging and decision support for critical laboratory abnormalities.

August 17, 2011

Trends in anesthesia-related liability and lessons learned.

March 6, 2019

Self-reported violations during medication administration in two paediatric hospitals.

May 16, 2012

A war on two fronts: cancer care in the time of COVID-19.

April 22, 2020

Another medical malpractice crisis?: Try something different.

October 14, 2020

Developing a medication patient safety program — infrastructure and strategy.

March 7, 2007

Classification of opioid dependence, abuse, or overdose in opioid-naive patients as a "Never Event".

August 5, 2020

A review of medical error reporting system design considerations and a proposed cross-level systems research framework.

April 4, 2007

Computer physician order entry: benefits, costs, and issues.

March 27, 2005

Patient safety: a consumer's perspective.

April 27, 2011

Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error.

December 7, 2016

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication.

June 3, 2020

Healthcare Utilizing Deliberate Discussion Linking Events (HUDDLE): a systematic review.

August 12, 2015

Determinants of patient–oncologist prognostic discordance in advanced cancer.

August 3, 2016

Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience.

May 30, 2018

Polypharmacy in hospitalized older adult cancer patients: experience from a prospective, observational study of an oncology-acute care for elders unit.

August 5, 2009

In situ simulation: detection of safety threats and teamwork training in a high risk emergency department.

June 5, 2013

Limited health literacy is a barrier to medication reconciliation in ambulatory care.

October 31, 2007

Self-reported adverse events in health care that cause harm: a population-based survey.

May 13, 2009

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

March 17, 2010

Emergency hospitalizations for adverse drug events in older Americans.

December 7, 2011

Burnout in healthcare: the case for organisational change.

August 28, 2019

SBAR improves communication and safety climate and decreases incident reports due to communication errors in an anaesthetic clinic: a prospective intervention study.

February 12, 2014

Wide variation and overprescription of opioids after elective surgery.

October 11, 2017

Using a computerized sign-out system to improve physician–nurse communication.

January 18, 2006

Computerized physician order entry: helpful or harmful?

March 6, 2005

Impact of the initial response to COVID-19 on long-term care for people with intellectual disability: an interrupted time series analysis of incident reports.

October 14, 2020

Opioid dependence and overdose after surgery: rate, risk factors, and reasons.

September 21, 2022

Emergency department visits for adverse events related to dietary supplements.

November 4, 2015

Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives.

August 23, 2017

Collaborative cohort study of an intervention to reduce ventilator-associated pneumonia in the intensive care unit.

March 9, 2011

Protocol-based computer reminders, the quality of care and the non-perfectability of man.

November 22, 2006

The critical incident technique.

March 27, 2005

An intervention to decrease catheter-related bloodstream infections in the ICU.

January 3, 2007

Assessing patient safety culture in hospitals across countries.

May 15, 2013

Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.

December 19, 2018

Sleep deprivation and error in nurses who work the night shift.

February 19, 2014

Safety II behavior in a pediatric intensive care unit.

August 1, 2018

Medication event huddles: a tool for reducing adverse drug events.

January 15, 2014

Related Resources

Annual Perspective

Equity in Patient Safety

March 27, 2024

Perspective

Artificial Intelligence and Patient Safety: Promise and Challenges

March 27, 2024

Interview

In Conversation with...Patrick Tighe about Artificial Intelligence

March 27, 2024

Systems approach to suicide prevention: strengthening culture, practice, and education.

June 28, 2023

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Perspectives on Safety

Annual Perspective

Technology as a Tool for Improving Patient Safety

March 29, 2023

Diagnostic stewardship to prevent diagnostic error.

March 15, 2023

Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis.

March 1, 2023

Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error

July 14, 2021

Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries.

July 7, 2021

An implementation science approach to promote optimal implementation, adoption, use, and spread of continuous clinical monitoring system technology.

January 27, 2021

COVID-19: an emerging threat to antibiotic stewardship in the emergency department.

October 21, 2020

Streamlining care in crisis: rapid creation and implementation of a digital support tool for COVID-19.

October 21, 2020

Expanding frontiers of risk management: care safety in nursing home during COVID-19 pandemic.

September 30, 2020

Assessment of health information technology-related outpatient diagnostic delays in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data.

July 22, 2020

Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.

July 15, 2020

Protecting children from iatrogenic harm during COVID19 pandemic.

July 15, 2020

Preparedness for COVID-19: in situ simulation to enhance infection control systems in the intensive care unit.

May 13, 2020

A review of adverse event reports from emergency departments in the Veterans Health Administration.

March 18, 2020

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care?

September 11, 2019

WebM&M Cases

Spinal Epidural Abscess

August 8, 2019

The design and conduct of Project RedDE: a cluster-randomized trial to reduce diagnostic errors in pediatric primary care.

May 15, 2019

Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study.

May 1, 2019

Inadvertent Administration of an Oral Liquid Medicine into a Vein.

April 1, 2019

Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.

December 5, 2018

Managing alarm systems for quality and safety in the hospital setting.

November 14, 2018

Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU.

February 8, 2017

Management of a patient with a latex allergy.

January 25, 2017

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

December 7, 2016

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Critical Pathways

Root Cause Analysis

Medical Alarm Design

The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site