Administration and Leadership, Columns

How Slipping Performance Becomes Acceptable

Issue 1 and Volume 40.

Throughout my career in EMS, as a paramedic and as an officer, I have noticed we experience various manifestations of “drift” in our practice. When I say drift, I mean deviating from rules and regulations, operational procedures, directives, guidelines, or other aspects of formal practice and performance expectations. These deviations can be seen in clinical, operational and administrative practice. Can you think of deviations in practice in your own organization?

Normalizing Deviance

Here are some examples from my experience:

>> Choosing to move a patient to the “safe and controlled” environment of the ambulance rather than initiating care at the patient’s side where you initially found them.
>> Being less than accurate as to where you are as opposed to where you’re supposed to be.
>> Cutting corners in infection control procedures.
>> Choosing to “pencil-whip” pre-shift equipment checks and checklists.
>> Reduced accuracy and completeness of patient care documentation due to time pressure.
>> Not being in full compliance with controlled drug policies.

Each of these deviations from policy and procedure can become acceptable over time. This phenomenon is called normalization of deviance.
The term “normalization of deviance”  was coined after studies of the Challenger space shuttle disaster, caused by failure of solid fuel rocket O-rings that sealed the sections of the solid fuel rockets. In EMS we won’t likely be part of such a spectacular, public and devastating failure, but there are lessons we can apply to our practice.

To correct normalization of deviance, reduce risk and improve practice, we need to understand the concept and recognize its presence before taking action. Let’s begin by examining how a particular aspect of paramedic practice can drift, deviate and, over time, become normalized.

Observing Deviance

I remember when I first started in EMS—volunteering as an EMT for a third-service emergency ambulance and later as a paramedic in the same organization—we always carried our “first in” bag, the LP-5 (yes, it was a while ago) and the O2 equipment in the orange hard case into a home.
We then completed an assessment and initiated care immediately.

While working as a shift supervisor at a hospital-based emergency ambulance service, I noticed that crews sometimes didn’t carry in the monitor on every case, or didn’t initiate IV access until the patient was in the back of the ambulance.

While in a fire department-based EMS system, I was called out by another paramedic for moving a patient to the truck before doing anything to address the patient’s needs.

As a paramedic shift supervisor in a fire department EMS system, I noted that this practice seemed very common and asked various paramedics why. Some said they wanted to be in a clean, controlled environment. Others said they were concerned about safety; they felt safer in their truck than in the patient’s house. Some said the rule was stupid and “The bosses just don’t know what it’s like out here.” Finally, some of the new medics said it was how they were taught by their partners; they were told, “This is how we do things here, kid.” I tried to change this practice but was unsuccessful.

When Did It Become OK?

There are several dimensions of this situation we can examine. First, as practice drifted, there were no bad consequences. Second, no one was working explicitly to determine the extent of the problem. And third, there was no systematic effort mounted to bring the medics into compliance.

EMS practitioners have been constantly pressured to “do more with less,” to meet response time criteria, to minimize hospital drop times and get back into service, and to document each patient contact completely. There are small incremental deviations that make things easier for practitioners, which continue and expand because nothing bad happens despite the deviation. It becomes accepted practice; the practice that was once a deviation becomes normal.


What can we do? Next time we’ll examine the causes of normalization of deviance in greater depth and discuss what we can do to reduce risk, move practice back into line with expectations and minimize drift over time that leads to normalization of deviance.