Reflection Day 1: Normalized Deviance

This first day of education has been a whirlwind of information, but nothing can compare to the personal stories of harm that has led to adverse outcomes.  Most of us as medical professionals have gone through an educational journey that teaches the importance of patient safety and quality, but it becomes so much more real when we listen to honest experiences shared by those who have lived it.  We could all speculate and say we would do things differently in that situation, but the truth is that medical errors are usually committed by good people with good intentions.

After reflecting on the movie that featured Lewis Blackman’s story, I began to wonder if a contributing factor to the critical error could have been a normalization of deviance in his vital signs.  If Lewis’ heart rate had shot up unexpectedly, or there was a sudden change in blood pressure, perhaps more providers may have realized that something was wrong.  But his heart rate slowly creeped up, so time progressed the care team could have thought, “Okay, this is his new normal.”  But it wasn’t okay, and it wasn’t normal.

Finally, I want to give a huge thank you to all the faculty members and everyone who have come together to make an educational experience that does more than show a PowerPoint.  This is an interactive educational experience that I will take with me throughout my career.