The danger of the ordinary and wrong

Thanks to Mike Davidge, at NHS Elect and NHS Wales, for sending along the link to an excellent talk by Gordon Caldwell, a consultant physician who works at Worthing Hospital in West Sussex.  It is essentially a primer on quality and safety improvement in hospitals and medical care in general.

Gordon actually made the video to practice a talk he was going to give a bit later, so it's not exactly a blazing cinematographic production.  It's simply a lovely exposition of key principles of process improvement.  He starts with three personal stories about patients and then draws lessons.

Somewhere about minute 11, this slide shows up, a concise definition of normalization of deviance, the tendency for the substandard to become the standard, a very important cognitive bias. (It is exemplified by the Columbia space shuttle disaster, left.)  This portion and the rest of the video present important lessons for us all.