Normalization of Deviance

by | Fostering an Improvement Culture

Patient Safety and Quality Improvement Lexicon

Normalization of deviance occurs when members of an organization become so insensitive to departures from standard practices or, deviant practices, that it no longer feels wrong. The process begins when a small deviation from practice standards does not cause harm. Other systemic pressures and inefficiencies (e.g. time, money, convenience) can  propel deviation. Employees become comfortable with the deviant process, and it becomes the new norm. Eventually, the deviant process (by itself or in concert with other deviant processes) results in a harmful outcome.

Patient safety efforts are particularly vulnerable to compromise from normalization of deviance. Consider handwashing.  It is frequent and repetitive, clinicians rarely “see” the harm they prevented, and it may be under-resourced by the organization (empty alcohol wash or paper towel dispensers). Further, patient safety efforts often rely on interdepartmental protocols, each of which may acquire its own normalization of deviance.  

Importantly, normalization of deviance represents a flawed patient safety system, and not flawed individuals. Identified sources of these flaws include:

  • Productivity pressuresthat compel individuals to use workflow short-cuts to meet output expectations (e.g. cursory reviews of lengthy prenatal survey responses).  
  • Negative acculturation, which describes how well-intended individuals adapt to and then conform with deficiencies in the existing culture (e.g. new physicians match established physicians’ inattentiveness during surgical time-outs).  
  • Complacency, which arises due to a blunted awareness of potential patient harm (e.g. personnel skipping handwashing).
  • Peer pressureto deviate, which can arise from complacent, fatigued co-workers working in a flawed system (e.g. medical assistants skipping the medication reconciliation to room patients as fast as their colleagues).   

Additional Resources:

  1. Price, M. R., & Williams, T. C. (2018). When doing wrong feels so right: normalization of deviance. Journal of patient safety, 14(1), 1-2. https://www.jstor.org/stable/26637542
  2. Wright, I. (2023). Normalization of Deviance Is Contrary to the Principles of High Reliability. AORN journal, 117(4), 231-238.