On January 28, 1986, the space shuttle Challenger disintegrated shortly after liftoff, resulting in the death of the entire seven-person crew. The subsequent investigation revealed that a joint in the right solid rocket booster failed during liftoff, which occurred due to the inadequacy of the O-ring seals. It was about 28-degrees on the morning of the space shuttle launch, and the O-ring seals were not designed to perform at such a cold temperature. Why then, given the suboptimal conditions, was the mission still a “go?”
The 2019 film “The Challenger Disaster” illuminates the multitude of factors that contributed to this tragedy. Ultimately, what happened can be summarized by sociologist Diane Vaughan’s philosophy of the “normalization of deviance.” She writes, the “normalization of deviance means that people within the organization become so much accustomed to a deviation that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.” In the case of Challenger, the performance of the solid rocket booster had deviated from expectations during previous launches. However, Vaughan explains, “[this] evidence [which was] initially interpreted as a deviation from expected performance was reinterpreted as within the bounds of acceptable risk.” In other words, the deviance became such a normal occurrence that those within the organization no longer even consider it to be deviant.
Of course, rocket scientists and engineers are not the only professionals who are susceptible to the temptation of deviating from the protocol. Unfortunately, studies have shown that health care professionals “consistently and even brazenly” neglect established protocols and standards of care. Over time, these deviations become normalized. Even in workplaces with carefully crafted policies, protocols, and procedures, there is often an unwritten understanding that the way things are done is not actually entirely aligned with the explicitly stated rules. For example, a phlebotomist may claim that it’s challenging to feel a baby’s vein through a latex glove, which is standard required personal protective equipment. As a workaround, she might put on the gloves as required “but then immediately tear off the index fingertip of one of them” so she can find the vein more easily.
It is important to note that deviations like this are “virtually never performed with criminal or malicious intent.” Therefore, when confronting the normalization of deviance, it is helpful to assume positive intent. In the example above, the phlebotomist didn’t intend any harm. She justified her behavior by claiming that it was in the best interest of the patient. After all, “she didn’t want to miss the vein and subject the baby to multiple sticks.” Most deviations are explained with similarly relatable reasons. Being a health care provider comes with high expectations and intense pressure — not only to ensure the best patient outcomes but to do so efficiently. The copious rules and regulations that are put in place are often perceived as hindrances that inhibit one’s ability to do their job well. A presentation from NASA acknowledges, “There’s a natural human tendency to rationalize shortcuts under pressure.”
Most of the time, nothing bad happens as a result of these shortcuts, but the very infrequency of serious catastrophes is one of the biggest contributing factors to complacency. The severity of the risk is “steadily downgraded according to the illogical idea that ‘if no accident has happened by now, it never will.’” However, Dr. Banja points out, “The recipe for disaster […] requires these errors, lapses or mistakes to go unattended, unappreciated, or unresolved for an extended period of time.” The Challenger tragedy is only one example of the consequences that can and do occur as a result.
When such egregious incidents take place and are found to have been preventable, everyone wonders why no one said anything. Why were these deviations simply permitted to continue for so long? The reality is, there are formidable psychological barriers that dissuade people from speaking up. Health care professionals, in particular, tend to sympathize with and support one another to a greater extent than those in other fields. Even so, this is no excuse for disregarding the measures that have been put in place to protect patients. Therefore, one of the first steps toward remedying the normalization of deviance is for health care professionals to continually recommit to the penultimate value of patient safety. We can also take time to reflect on “the gravity and repercussions of an adverse event’s actual occurrence.” Perhaps, this will help motivate us to break bad habits and hold one another and ourselves accountable. By intervening early and consistently to correct deviations, many tragedies can be prevented.
Shannon Casey is a physician assistant.
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