One of my favourite terms is the “Normalisation of Deviance”. I think it captures perfectly what happens every day in healthcare. We work around problems, pat ourselves on the back for finding a (temporary) solution, and ignore the very profound message that the system is sending us; this message essentially is “you dont understand your system and your processes and if you dont work out a way to fix this problem, there will be serious consequences”. In
Reasons Swiss Cheese model, all those little holes are problems that usually were recognised well before a serious event occured, but were most often ignored and certainly never consciously addressed and removed.
As Scott Snook, a lecturer from Harvard puts it:
Each uneventful day that passes reinforces a steadily growing false sense of confidence that everything is all right – that I, we, my group must be OK because the way we did things today resulted in no adverse consequences.
A paper that describes the consequences of this thinking, really a form of magical thinking is available on the NASA website; it is a section of the report into the Columbia Space Shuttle disaster.
Available here.
