Certified Professional in Patient Safety (CPPS) Practice Exam

What concept best explains the situation where inconsistent sponge counts lead to a surgical error?

1. Normalized deviance.

2. Malicious intent.

3. Workarounds.

4. Checklist fatigue.

The correct answer is: Normalized deviance.

The concept of normalized deviance best explains the situation of inconsistent sponge counts leading to a surgical error because it refers to a phenomenon where individuals and teams in an organization become accustomed to taking shortcuts or deviating from established protocols without recognizing the risks involved. In the context of surgical procedures, if teams frequently encounter discrepancies in sponge counts and begin to accept those inconsistencies as part of normal operations, they can inadvertently foster an environment where adherence to safety protocols is compromised. This gradual acceptance of deviations can create a culture where errors are more likely to occur, as the importance of consistent counts may be diminished over time. Essentially, normalized deviance underscores the danger of ignoring established safety practices, highlighting the need for continuous vigilance and adherence to standards to prevent adverse events in patient care. Understanding this concept emphasizes the importance of reinforcing safety protocols and ensuring compliance to mitigate risks associated with surgical errors.