The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

There are many elements that contribute to errors within an industry or profession. Several human factors associated with safety breakdowns are outlined in Table 2. Experience and root-cause analyses usually document that 2 or more of these factors coalesce to form a "perfect storm" leading to a mishap. For example, expecting a fatigued provider to care for an emergency patient with concurrent production pressure to maintain the elective schedule, while using new and unfamiliar equipment, is a potent mix of risk factors. As Gaba et al. pointed out, production pressure "is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions." One solution is to integrate standard protocols and expectations for safe practice and expected behavior throughout the practice. Other potential solutions may involve the design of better and "smarter" monitors that will reduce the noise pollution and attendant distractions in the OR, and variable priority training that helps clinicians focus on "optimal distribution of attention when performing multiple tasks simultaneously with the goal of flexible allocation of attention." We have also observed the phenomenon of intersecting curves of knowledge versus experience. When we exit our organized training period, our knowledge base is strong. We have studied for specialty examinations, experienced the idealized purity of an academic environment, and have been taught the "right way" to practice by our mentors and role models. As the years pass, our minute, detailed knowledge may decrease, but our practical experience increases greatly, and patient care and safety are assured. However, as we are increasingly challenged to "do more with less," the temptation will arise to "cut a few comers" where we can to achieve productivity and efficiency benchmarks. To that end, we caution our colleagues to avoid the slippery slope of accepting a decrease in vigilance and safety while striving for "faster, better, cheaper." We encourage every individual to maintain vigilance, advocate for patient safety, aim for excellence and efficiency, and avoid the temptation of normalizing deviance from accepted safety standards.