Medical-Legal Topics

Normalization of deviance occurs when a provider, such as a nurse, knowingly disregards a safety practice, like using two patient identifiers to verify patient identity. Repeated deviation from the safe practices tends to “normalize” the risky behavior in the nurse’s mind. In another example, The Joint Commission Medication Management Standard requires labeling of all medications. Yet a survey by the American Nurses Association indicated that only 37 percent of nurses surveyed reported they always label syringes and 28 percent never label syringes when administering medications.

Despite awareness and education, some providers choose to willfully disregard safety practices. Patient safety experts define a “no blame” culture as one that argues that most errors are committed by hardworking people; the traditional focus on identifying who is at fault is a distraction. A “just culture” differentiates between blameworthy and blameless acts. Two physicians, Wachter and Pronovost, acknowledge that there are areas of performance that pose a clear risk to patients, such as failure to practice hand hygiene, use a checklist to reduce blood stream infections, mark the surgical site to prevent wrong-site surgery, or perform a preoperative time out.

Nurses are implicated in some of these issues. They work for the organization, which typically has relatively clear lines of authority and procedures for dealing with failure to follow accepted practices. On the other hand, physicians have traditionally been independent entrepreneurs, not employees. They are subject to weak peer enforcement. Peers often recoil from disciplining each other and hospitals have been reluctant to punish physicians for fear of alienating them and losing the business they bring in. The tradition of lax enforcement of safety rules has led too many physicians to ignore them. Wachter and Pronovost argued for a clear definition of unacceptable behaviors, with the initial warnings and counseling. Continued failure to adhere to safety practices after the initial penalty would lead to suspension or loss of clinical privileges (for physicians and others subject to credentialing, such as advanced practice nurses) or firing.

Isn’t it about time we stopped dangerous practices?

More reading:
Beaulieu, L. and Freeman, M, “Nursing shortcuts can shortcut safety”, Nursing 2009, December 2009, 16-20
Wachter, R. and Pronovost, P., “Balancing ‘no blame’ with accountability in patient safety”, New England Journal of Medicine, October 1, 2009, 1401-1406.
Cohen, M. “Risky imposter”, Nursing 2008, May 2008, 20.

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