Nursing shortcuts can shortcut safety.

AS RITA JONES LOOKS at her watch, she realizes she's 20 minutes late giving medications to the two patients in room 607. Rita goes to the automated medication dispensing system and takes out medications for both patients, one after the other. Rita races to the room with both patients' medications in hand and unknowingly gives each patient the other's medications. Only after one of the patients refuses to take a tablet because it's different than what he's taken in the past does Rita realize her error. Unfortunately, the other patient has already taken his medications. Rita is very upset and can't understand how this happened; she's used this shortcut many times and never made an error. Errors such as these highlight the danger of bypassing standard safety practices. Healthcare organizations are developing practices and protocols to support a culture of safety and to eliminate or minimize preventable errors. How to create and measure a culture of safety has been discussed extensively in the literature. This discussion, however, has failed to consider the normalization of deviance, which occurs when a nurse knowingly disregards a safety practice, such as using two patient identifiers to verify patient identification. Repeated deviation from safe practice tends to "normalize" the risky behavior in the nurse's mind. This article examines normalization of deviance and discusses how nurses can support a culture of safety by discouraging and avoiding risky shortcuts. Breaking the rules The normalization of deviance occurs when a nurse knowingly breaks the rules in the belief that an unsafe practice is acceptable. Because the rules have been broken in the past without patient harm, the nurse assumes that they can be safely bypassed to save time. The normalization of deviance was first brought to public attention by Diane Vaughan in her sociological study of the Challenger disaster. National Aeronautics and Space Administration engineers accepted technological problems because of administrative pressure to launch the shuttle and a false belief that previous successful launches with these defects meant there would be no consequences.1 The normalization of deviance has also been identified as a problem in other high-risk organizations, including aviation and nuclear power. This dangerous phenomenon must be understood by direct caregivers and by nurse managers, administrators, and educators so it can be addressed and eliminated. Although the direct impact of the normalization of deviance on healthcare errors isn't known, in other industries it clearly contributes to many adverse events.2 Why does it happen? The normalization of deviance occurs when unsafe practices are accepted as the norm. Phrases like, "this is the way we do things here" or "you did it that way in school, but the real world is different" are all too familiar in the workplace. In practice and when teaching nursing students, we've observed nurses ignoring many safe practices, including those involving hand hygiene, standard precautions, infection control, and medication administration. Normalization of deviance can occur at any step in the medication delivery process. For safety, nurses are expected to follow the seven rights of medication administration: the right patient, drug, dose, route, time, and response, and the right to refuse. But many nurses are remiss about performing one or more of these known safety practices for reasons such as saving time. The need to be fast, efficient, and effective now permeates nursing practice. At times, getting things done takes precedence over safety. Cutting corners, using work-arounds, and even ignoring safety policies can become the norm. Nurses may continue to skip safe procedures until a serious error forces them to take a second look at using safe practices as a strategy to prevent harm. Although nurses don't intend to injure patients, intentionally breaking the rules places patients at risk for adverse events. What can nurses do? Adhering to safe practices and refusing to use deviant behaviors can help to control the risk to patients. The following strategies are recommended: Nurse managers must be clear about requiring staff to follow facility policies and procedures for safe practices. Continually monitoring policies and procedures and providing feedback to staff about their performance sends an obvious message about the value of patient-safety policies. Emphasizing the importance of 100% compliance with nonnegotiable safety practices, such as performing hand hygiene, demonstrates the facility's dedication to safe care. Nurses must reinforce and model desired behaviors. The nurse who discovers unsafe policies or procedures must report them so they can be addressed quickly. Nurses who don't follow safe practices must be approached and educated about the danger. For example, if nurses aren't cleaning stethoscopes between patients, the nurse manager should bring this behavior to their attention and explain the risks to the patient, nurse, and institution. Nurses must also be educated about the causes of error. How errors occur and situations that provoke error, including initiation overload, can be topics for staff-development sessions. (Initiation overload is when many initiatives are being implemented simultaneously or one after the other, causing the staff to feel overwhelmed and overburdened.) When nurses understand where deviance is coming from, they can become involved in preventing it. When an error occurs, nurse managers must act on this opportunity for teaching. For instance, if a nurse administers the wrong medication to a patient, the nurse manager must help the nurse recognize the unsafe practice that led to the error. If failing to check that the patient's name and date of birth on the armband matched the name and date of birth on the medication administration record was one reason for the error, help the nurse to see that changing this behavior will make medication administration safer in the future. Nurse managers must recruit staff members who value continuous learning and safe practice. Interviewing and orienting new staff can provide an opportunity to focus on these topics. Asking situational questions that require the nurse to think critically and provide responses to situations that pose obstacles to patient safety and safe practices can give the nurse manager some idea of the nurse's future practice. The organization's publications should communicate the value of safety. Publications that showcase lower infection rates in certain units or congratulate staff members who've made contributions to improve practices demonstrate the organization's commitment to safe practices. Nurse managers must appeal to nurses' desire to protect and help patients by emphasizing how following safe practices benefits the health of their patients. Rooting out unsafe practices To cultivate a culture of safety, nurses must reevaluate practices and beliefs about error. Recognizing that the normalization of deviance contributes to errors provides a new perspective for developing error reduction strategies. Working together, nurses can make healthcare safer for patients by rooting out the normalization of deviance.