Normalization of deviance a constant risk

It is human nature to take shortcuts or ignore the burdensome steps sometimes involved in doing a task the right way, and when there is no negative consequence, the deviation can be reinforced.

Then the next time that person does the task, it becomes easier to take the shortcut. Before long, it doesn't even seem like a shortcut. It just seems like the normal way to do the task.

That acceptance of a wayward behavior is called "normalization of deviance," and it poses a significant risk in health care, says John Banja, PhD, assistant director for health sciences and clinical ethics at Emory University in Atlanta. The problem can occur in any industry, but the deviation from proper procedure can have a direct effect on safety in health care, he says.

"System operators — in this case, doctors, nurses, and other health care workers — will often perform a task differently from how they were taught to do it, or the way policy and procedure, or regulations, or standards of care say they should," he says. "They don't deviate to be malicious. Usually, they deviate to save time or because they think the regulation is unnecessarily burdensome. They firmly believe they are not heightening risk, and when they start doing things their way, everything initially is fine. But sooner or later, disaster happens."

Normalization of deviance doesn't affect just one person, Banja says. It can spread throughout a workplace even if it starts with just one person, he says.

"Interestingly, as their deviance continues, people around them start noticing it, and if the deviator is a role model or someone with authority, underlings might start performing the deviation as well," Banja says. "It becomes the norm. Doctor Jones is doing it, so it must be OK, right?"

The normalization of deviance can be insidious, and it may stay under the radar of risk managers and upper management, Banja warns. Quite often, he says, health care providers are conscious of their deviation from the proper way to perform a task and are ready to respond with the correct answer when asked what they should be doing. But everyone on the floor knows that they really do the task differently because their way is "better" or "faster" or "easier" and "that's just how we do it here."

Can have positive deviance

But interestingly, normalization of deviance isn't always about people taking the easy way out. Maurice A. Ramirez, DO, BCEM, CNS, CMRO, an emergency physician at Pascoe Regional Medical Center and president of the consulting firm High Alert, both in Kissimmee, FL, says it also is possible for health care providers to normalize a higher level of care than necessary.

"There are two dangers with normalization of deviance. Deviance generally occurs on both sides of the mean curve," he says. "Negative deviance creates a cascade of unforeseen consequences when institutionalized."

Examples of negative deviance include prescribing antibiotics for viral infections, using Betadine on lacerations before suturing, ordering tests before examining the patient, assuming that the irregular waveform on the cardiac monitor is patient motion and not an arrhythmia.

However, Ramirez says a positive deviance (too much of a good thing) also creates a cascade of unforeseen consequences when institutionalized. This deviance also can become the norm if not checked, Ramirez says.

Examples of positive deviance include treating the lab value even when there is no associated disease or symptoms, or assuming that every patient complaint is an accurate and complete account of all aspects of the event before investigating and changing care based on that assumption.

A particularly dangerous aspect of the normalization of deviance is that a deviation can be harmless for a long time and then cause a tragic adverse outcome, Banja says. Disaster analysis has shown that most industrial accidents — everything from the loss of the space shuttle Columbia in 2003 to the 1984 chemical accident in Bhopal — can be traced to a normalization of deviance.

In health care, as in many situations, the deviation often seems harmless or minimally risky on its own. But over time the deviation eventually leads to a tragedy.

"Examples can include not washing your hands, not gowning up or skipping other infection control measures, not changing gloves or instruments when you should, failing to check wristbands, using abbreviations, not getting the proper consent or approval before proceeding, and violating your policies on the storing and dispensing of medications," Banja says.

Encourage reporting deviation

So how does a risk manager counter the normalization of deviance? It's not as easy as saying "don't do it," because that's part of the nature of this normalization, Banja says. People know what you expect and do it differently anyway. Banja says a key to interrupting the normalization process is for leadership to become aware of the deviance. If only the people working together in the operating room, for instance, know about a shortcut being taken, then no one will interfere, and the shortcut will be normalized.

"In the case of deviators who take excessive, dangerous risks, they are often not reported although they are known," he says. "That's the point: the gossip does not rise to a high-enough level so that supervisors, et cetera, can attend to it. At any hospital, 80% of the doctors and nurses know which ones should not be in the hospital, because they're not doing things the right way and putting patients at risk. They talk among themselves but not to you."

That is why Banja favors a concept he calls "good gossip." Gossip typically is derided as always negative and counterproductive, but Banja says the health care community should encourage communication about deviations. The risk manager must promote a culture in which people understand that deviance and nonconformity are inevitable, and that those who report them will not be punished. One way to encourage reporting is to show that a deviation will not always result in negative consequences.

"It's possible that once it is brought to your attention and investigated, you will find that the regulation they were trying to avoid is indeed too cumbersome and unnecessary," Banja says. "In that case, you can change it, so that they don't have deviate and try to keep it secret. Of course, there will be other situations in which you have to make sure the deviators don't perform their shortcuts, and that is an opportunity to reinforce your commitment to patient safety."

Discuss deviation publicly

Banja also recommends these strategies for eliminating deviations before they become normalized:

• frequent rounds;

• surveys of incident reports;

• root-cause analyses;

• focus groups.

Distribute your findings on system deviations at committee meetings, grand rounds, continuing medication education meetings, and inservices. Make deviation a frequent topic of discussion in a nonpunitive way so that it becomes the norm to talk about it rather than not talk about it.

"We should always keep it in the forefront of our organizational mindset," Banja says. "It's just a fact that people will always deviate. People are pressured to perform, they have too much work, too little time, and they are going to cut corners sooner or later. We have to accept that this is human nature and constantly remind people not to let it become normalized."


For more information on normalization of deviance, contact:

• John Banja, PhD, Assistant Director for Health Sciences and Clinical Ethics, Emory University, Atlanta. Telephone: (404) 712-4804. E-mail:

• Maurice A. Ramirez, DO, BCEM, CNS, CMRO, Kissimmee, FL 34744-5151. Telephone: (407) 301-3458. E-mail: