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Errors and matters of judgment


Even good doctors make mistakes

Violations


Violations usually refer to deviations from policies and procedures that help facilitate clinical care. Although violations may be intentional, the harm to a patient that sometimes results is not intentional.

Types of violations include:

  • routine: cutting corners
  • necessary or situational: the policies or procedures are inappropriate to the specific patient's circumstances
  • rogue: reckless behaviour without concern for the well-being of others

People often find ways of getting around workplace processes that are viewed as unnecessary or impeding workflow. Such "workarounds," which are common in healthcare, are nonstandard methods to bypass or deal with a recognized problem in a system or process of care.

While a workaround may benefit an individual patient by fixing a problem specific to that case, the dysfunctional system or process of care is typically not corrected and not reported, continuing the risk for future patients.

Normalization of deviance

Normalization of deviance is the gradual acceptance of cutting corners and workarounds over time.

The Challenger on launch pad

NASA and the Challenger space shuttle

In the 1970s the United States began to build reusable spacecraft to transport people and cargo. The shuttle Challenger flew 9 successful missions before the rocket began to break apart seconds after a takeoff in 1986, killing all 9 astronauts aboard.

The subsequent investigation revealed:

  • NASA was under great pressure to launch
  • it was a colder than usual day
  • large rubber O-rings in the booster rocket failed in the colder weather, allowing hot gas to leak and damage other essential components

Engineers had known for several years there were flaws in the O-ring design and materials. The team came to accept this lower standard (normalization), believing the success of previous launches meant future success. The use of substandard O-rings became routine and the engineers forgot the potential consequences if the O-rings were to fail.

The tragedy was predictable.

The engineers did not speak up because they were lulled into complacency.
"We wished that we had the foresight to stand up collectively and say, 'Look, it's too cold a day to launch, we just ought to wait for a warmer day.' In retrospect it seems so simple; at the time, it just didn't happen."

The impact of normalization of deviance in healthcare

Violations of recognized standards of practice for patient care can become "normalized" or routine over time.

Here are some common examples:
  • Not washing or sanitizing hands before and after examining patients.
  • Not gowning and taking appropriate infection control measures.
  • Disabling alarms on patient care equipment such as ventilators.
  • Disabling alarms on security doors in psychiatry or geriatric wards.
  • Ignoring or turning off alerts in an electronic medical record (EMR).

Think about it

Can you think of other violations of recognized standards of practice for patient care?

Case: A child in the operating room
Side view of male hospital staff adjusting monitor

Background

A toddler requires general anaesthesia in a small community hospital.

The anaesthesiologist, the operating room (OR) team, and hospital administration are all aware there is an ongoing problem with the available capnometer which necessitates silencing the monitor alarms.

Despite this, the anaesthesiologist does not check the alarms for function or volume prior to surgery, and does not set alarm limits appropriate to the patient's age on the other monitoring equipment (e.g. oxygen saturation, electrocardiogram).

Outcome

Following induction, the nasotracheal tube dislodges from the trachea.

The child develops hypoxia that goes unnoticed because the alarms are not audible.

Cardiac arrest follows, resulting in anoxic brain damage, bilateral blindness, and aphasia.

Think about it

How could this harm be avoided?

Suggestions

Knowing there is a problem with the capnometer:
  • The hospital should fix the equipment problem.
  • The anaesthesiologist should check the alarms on the other monitoring equipment (e.g. oxygen saturation, electrocardiogram) to ensure they are functioning properly, set age-appropriate alarm limits, and set the audible alarms at a sufficient level.

Suggestions continued

Knowing there is a problem with the capnometer:
  • The anaesthesiologist should pay closer attention to the visual indicators on the monitoring equipment.
  • Both the anaesthesiologist and other members of the OR team should observe the child more closely for signs of hypoxia and cyanosis.
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