When Poor Practice Becomes Normal: The Hidden Danger Inside Every Organisation
Introduction
All major disasters share a common element that often goes unnoticed until it is too late.
They rarely result from a single individual making a catastrophic mistake that leads directly to a calamitous event. Rather, they typically originate from something more subtle and insidious that develops over time.
Someone takes a shortcut, perhaps believing it to be a minor adjustment in an otherwise sound process.
No adverse outcomes occur immediately, which reinforces the notion that the shortcut is harmless.
As a result, the shortcut is repeated, creating a pattern of behaviour that seems increasingly acceptable.
Again, no immediate consequences are observed, and with each successful iteration, the sense of risk diminishes.
Eventually, this practice becomes widespread, ingrained in the culture of the organization or system.
Over time, the initial perception of it being incorrect fades, overshadowed by a false sense of security.
Safety does not disappear suddenly; rather, it diminishes gradually, eroded by the normalization of behaviours that once would have been considered unsafe.
This gradual decline in safety is a process known as:
The normalization of deviance.
This concept was introduced by sociologist Diane Vaughan during her thorough investigation of the Challenger Space Shuttle disaster. Engineers had repeatedly observed erosion of the shuttle's O-ring seals in previous launches. However, as each mission succeeded without incident, these warning signs were increasingly viewed as "normal." The absence of disaster was mistakenly interpreted as proof of safety, until the moment it was not, leading to catastrophic consequences.
Implications for Healthcare
The healthcare sector is not immune to the normalization of deviance; in fact, it may be particularly vulnerable to its effects.
Hospitals operate under extreme pressure and face numerous challenges that can compromise safety. Factors such as staff shortages, overwhelming waiting lists, financial constraints, and rising patient demand drive clinicians to seek more efficient methods of operation. Most of these adaptations begin with good intentions, aimed at improving patient care and operational efficiency.
The issue arises when the pursuit of efficiency and safety do not align, creating a precarious balance.
For example, a checklist might be shortened because "everyone knows the patient," leading to critical information being overlooked.
An alarm might be silenced because it "frequently goes off," causing important alerts to be disregarded.
Documentation might be completed afterwards due to time constraints, resulting in incomplete or inaccurate patient records.
Consent discussions might be abbreviated because the clinic is running behind schedule, potentially compromising informed consent.
These decisions are not intended to harm patients; they stem from a desire to manage time and resources effectively.
Each decision seems entirely reasonable when considered independently, yet the risk lies in their repetition.
Over time, the exception becomes the norm, and what was once a deviation from standard practice is accepted as standard procedure.
This is the normalization of deviance in action, where small, seemingly innocuous changes accumulate to create a significant risk.
Organizational Awareness
A significant insight from recent healthcare literature is that organizations seldom recognize this detrimental process as it unfolds. Instead, success reinforces unsafe practices. Each day without an adverse event strengthens the belief that the shortcut is acceptable and safe. Ironically, the absence of harm becomes the rationale for persisting with the risk, creating a dangerous cycle of complacency.
High Reliability Organizations (HROs) operate differently and offer a model for the healthcare sector to aspire to. In fields such as aviation, nuclear power, and aircraft carriers, these organizations maintain what researchers describe as a preoccupation with failure. They do not assume that present success indicates safety. Instead, they consistently look for weak signals, near misses, and minor deviations before they escalate into disasters, fostering a culture of vigilance and proactive risk management.
The healthcare sector often struggles with this mindset, as it is natural for professionals to celebrate successful outcomes and focus on positive results.
However, we seldom recognize the clinician who identifies a latent safety risk before any harm occurs, often overlooking the importance of these preventive actions.
As an expert witness reviewing clinical negligence cases, I have observed a pattern that transcends individual specialties and clinical settings.
Rarely does a single isolated error account for the outcome of a negative incident.
Rather, it is often a series of accepted workarounds, assumptions, and minor deviations from expected practices that build upon each other. Each seemed reasonable at the time, yet collectively they paved the way for harm to occur.
This should not be seen as criticism of individual clinicians, as most healthcare professionals are striving to do their best in systems that place immense demands on them.
The question is whether the system subtly fosters behaviors that were once deemed unacceptable, creating a culture where shortcuts become the norm.
This is a much more challenging conversation to have, yet it may be one of the most crucial discussions that healthcare needs to undertake in order to improve patient safety and care quality.
Discussion
Have you ever worked in an environment where people said:
"We've always done it this way."
Was it a testament to experience, a reflection of established practices...
...or had poor practices gradually become normalized over time, leading to a culture of complacency?
Reflecting on these questions can reveal much about the dynamics of safety and risk within any organization. It prompts a necessary examination of how practices evolve and the implications they carry for both staff and patients alike.
Comments