Presented By: Pete Cherouny, M.D.
January 2013

What do the space shuttle mission, the Titanic, the Exxon Valdez, the Deepwater Horizon disaster and the 2008 financial collapse have in common with healthcare? Find out as we reconstruct these system failures and evaluate the deeply human traits of deviating from standard practices, developing the rationale for that deviation, and, finally, the normalization and progression of the deviation over time that puts our systems and lives at substantial risk. Dr. Peter Cherouny, professor of OBGYN at the University of Vermont and faculty at the Institute for Healthcare Improvement, discusses how to identify and manage unsafe practices before they become the �norm� in our own practice setting.

Objectives:

• Describe the concept of normalization of deviance from system standards
• Recognize the reasons we drift from standards in our personal and professional lives
• Cite examples of bad outcomes caused by normalization of deviance from standards in industrial, technologic and healthcare settings
• Explain the difference between operating within areas proven to be safe vs those not proven unsafe