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Banja: Shortcuts and normalization of deviance
Do workarounds equal unethical behavior?
While not every physician or nurse makes a decision to deviate from standard medical practice or rules and regulations governing that practice, it certainly does happen, according to John D. Banja, PhD, professor, department of rehabilitation medicine and medical ethicist, Center for Ethics at Emory University School of Medicine in Atlanta.
For example, according to Banja, anesthesia monitoring shortcuts are rather common. In one study, about 17% of anesthesiologists were found to remove blood pressure and/or ECG cables before the patient's emergence from anesthesia and tracheal extubation.1
Other common deviations or "process variations" are not washing or sanitizing hands sufficiently; not gowning up or skipping some other infection control measures; not changing gloves or instruments when appropriate; not performing safety checks; or not getting required consents or approvals before acting, according to Banja.
In a December 2008 study, "Adverse Events in Hospitals," from the U.S. Department of Health and Human Services' Office of Inspector General, only 25% of 1,256 hospitals surveyed followed all 27 National Quality Forum safe practice guidelines.
While such lapses in following standards of care may not constitute unethical medical practice, Banja suggests that it is "ethically worrisome."
"It is ethically concerning," he says. "The reason why it's ethically concerning is that, well, there's no question that in many instances, these kinds of shortcuts or workarounds or deviations from the standard of care, policy, procedure or rule, that they will doubtlessly dispose patients to a higher level of risk. And that is what is concerning, because obviously, the higher the level of risk becomes, the more we are endangering patients, and we ought not to be doing that."
A huge reason why health professionals feel it is perfectly acceptable to deviate from rules and standards is that when they do so, nothing bad happens, according to Banja.
"Indeed, the deviation almost always occurs because the professional finds it more expedient to do it that way. They never intend to be malicious. Rather, they simply want to perform their tasks more rapidly and efficiently," Banja explains. "So, now, because they can do it faster by omitting step number 3 or 7 or whatever, that deviation becomes routine, and thus, in their eyes, no longer a deviation.
"In fact, they might even teach 'their way' to new personnel," he says. "Disaster occurs when their shortcut mixes with other rule and standard violations, and the system can no longer intercept mistakes, errors, or the beginnings of an adverse event."
Banja noted that virtually all instances of disasters and catastrophes exhibited a long history of rule and standards violations before the catastrophe occurred.
"Only later, after the untoward event went down, do we shake our heads and say, 'How could we have allowed all this to happen, when we knew that it was dangerous?'" Banja says.
The fact that perhaps nothing immediately bad happens when there is an omission of steps in treatment or a procedure "is what oftentimes will lull us into a state of complacency," he notes.
"Years may go by where people are actually being quite careless and not paying enough attention to weaknesses and flaws and problems in the system, where it might make an error easier to happen, [but] once the error occurs, it might result in a disaster," Banja explains.
That, he notes, is an important point, i.e., to differentiate the error from the harm the error causes.
"In fact, most errors that happen in hospitals don't cause patient harm," Banja says. "It's when, for example, the wrong medicine is coming up to a floor in a hospital from pharmacy, and it's the wrong medicine it's not the medicine that the doctor ordered. Someone on the unit then gets that medicine, but then doesn't check it out and gives that medicine to the patient. In most instances, most patients don't get harmed by that, but sometimes they do."
Why deviate from standards?
There is a long list of reasons that a physician or nurse may deviate from standards. Often, they think the rules are "stupid, too cumbersome, inefficient, etc." Sometimes, it is because a health care provider has not received proper training or he or she has received training but is perhaps not able to adapt to a new way of doing things.
Another reason is "nonconformities are not identified or are kept secret," according to Banja, who makes frequent presentations to physicians and nurses on this topic.
Other times, a physician or nurse may think their way is simply better or faster. According to Banja, it could be the mark of a "caring employee," who believes he or she has found a better way to do something that he or she believes will be beneficial.
Shortcuts are often adaptations to the complex hospital environment, which like many large operations, often runs in a "degraded mode," Banja says.
One of the authorities on this topic of "system failures," he says, is James Reason, author of "Human Error," who likes to use the term "resident pathogens," he says.
"Anything that can weaken a system's ability to detect and intercept errors, such as sleep-deprived personnel, high levels of stress, admitting patients whose acuity level outstrips resources, equipment failures, poor documentation and communication, even dim lighting those are pathogens in the system," Banja explains. "They might not result in catastrophe, but they make the system weaker: less immune, less, so that, when something bad does happen, that bad thing can then proceed to cause a disaster."
Ways to guard against deviations
One of the problems in guarding against or eliminating deviations in standard of care once they have started is that those clinicians and nurses who may be aware of such "problematic actors" don't speak up, according to Banja.
"You go to any nurse, any doctor who works at a hospital and say, 'Would you think that 80% of the nurses on any unit know which ones are dedicated, competent, and reliable and which ones aren't?'"
And, Banja says, often they will answer, "Sure; we know; we know who they are."
"But the problem is: These people persist at institutions; they endure at institutions, because it's very difficult to speak up about them," he explains.
These "system operators" may "fear speaking up" or believe that if they do speak up and report those engaging in potentially dangerous medical practice, nothing will be done within the system to address it. Or, it could be that monitoring and investigating such incidents never occurs or is completed ineffectively.
Sometimes, "deviant behaviors spawn more deviant behaviors and system failures begin to interact with one another," according to Banja.
Other times, it is because the individual who considers reporting a problematic physician or nurse fears retribution or doesn't want to get that individual in trouble.
"Again, it's very, very difficult to confront another professional," Banja notes. "Doctors are notorious about this."
Because speaking up against another professional is so contrary to "human nature and our own sense of safety, and self-protectiveness . . . organizations have to take the initiative to create what we might call 'safe' speaking up environments. In other words, we need to create an atmosphere in this organizations where people will feel safe when they speak up about one another that is to say they will have confidence that they won't be retaliated against, and perhaps they'll have the confidence that the first reaction, or the first response of the institution to that individual, who is acting in an eccentric fashion, is not going to be . . . blame and punishment."