Normalization of Deviance Is Contrary to the Principles of High Reliability

Normalization of deviance is a phenomenon in which individuals and teams depart from an acceptable performance standard until the adopted way of practice becomes the new norm. This phenomenon is concerning in high-risk areas of health care because it erodes a safety culture. Additionally, it is inimical to the principles of high reliability-specifically, to the first of the five principles: preoccupation with failure. Although all high-reliability principles hold relevance to safety, preoccupation with failure describes a consistent alertness to risk and is critical for preventing adverse events, particularly in high-risk environments such as the OR. This article describes how normalization of deviance and preoccupation with failure cannot coexist and presents ways to mitigate normalization of deviance and bolster high reliability, ultimately making ORs safer for surgical patients.