Sunday, June 21, 2015

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.

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