The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

There are many elements that contribute to errors within an industry or profession. Several human factors associated with safety breakdowns are outlined in Table 2. Experience and root-cause analyses usually document that 2 or more of these factors coalesce to form a "perfect storm" leading to a mishap. For example, expecting a fatigued provider to care for an emergency patient with concurrent production pressure to maintain the elective schedule, while using new and unfamiliar equipment, is a potent mix of risk factors. As Gaba et al. pointed out, production pressure "is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions." One solution is to integrate standard protocols and expectations for safe practice and expected behavior throughout the practice. Other potential solutions may involve the design of better and "smarter" monitors that will reduce the noise pollution and attendant distractions in the OR, and variable priority training that helps clinicians focus on "optimal distribution of attention when performing multiple tasks simultaneously with the goal of flexible allocation of attention." We have also observed the phenomenon of intersecting curves of knowledge versus experience. When we exit our organized training period, our knowledge base is strong. We have studied for specialty examinations, experienced the idealized purity of an academic environment, and have been taught the "right way" to practice by our mentors and role models. As the years pass, our minute, detailed knowledge may decrease, but our practical experience increases greatly, and patient care and safety are assured. However, as we are increasingly challenged to "do more with less," the temptation will arise to "cut a few comers" where we can to achieve productivity and efficiency benchmarks. To that end, we caution our colleagues to avoid the slippery slope of accepting a decrease in vigilance and safety while striving for "faster, better, cheaper." We encourage every individual to maintain vigilance, advocate for patient safety, aim for excellence and efficiency, and avoid the temptation of normalizing deviance from accepted safety standards.

Men are more susceptible than women to direct pressure on unmyelinated ulnar nerve fibers.

UNLABELLED: Ulnar nerve injury, the most common form of perioperative peripheral nerve injury, has a 3:1 male/female predominance. Neither the mechanism of perioperative ulnar nerve injury nor the reasons for the increased male susceptibility are well understood. We used an experimental model with arm flexion at the elbow, direct pressure on the ulnar nerve, and arm ischemia as distinct stress mechanisms to induce adverse changes in ulnar current perception thresholds (CPTs) on 3 groups of 40 male and 40 female volunteers (a total of 240 volunteers). CPT measurements were repeated at 2000-, 250-, and 5-Hz stimulating frequencies, specific to A-beta, A-delta, and unmyelinated C-fibers, respectively. Ischemia produced significant increases in CPT with all three stimulating frequencies, and there were no detectable differences between men and women. Flexion failed to produce significant CPT increases at any of the three stimulating frequencies, with no sex-based differences. Direct pressure produced significant CPT increases at 5 and 250 Hz, indicating inhibition of both unmyelinated C-fibers and myelinated A-delta fibers. C-fibers, but not A-delta fibers, demonstrated sex differences with direct pressure; there was a 1.7-fold (95% confidence interval, 1.2- to 2.4-fold) greater effect in men. Ischemia significantly inhibited the function of all three fiber types, perhaps sufficient to overwhelm gender differences. IMPLICATIONS: The ability of direct pressure to produce a greater inhibition of unmyelinated C-fibers in male subjects compared with female subjects is consistent with, and may help explain, the male increased susceptibility to perioperative ulnar nerve dysfunction.

Ulnar nerve injury and perioperative arm positioning.

Primum non nocere. Hippocrates included this admonition in Epidemics, Book I, Second Constitution, to do good or "to do no harm." However, even the most conscientious health care provider will encounter unexpected and serious adverse medical events. This discussion focuses on one relatively common, often perplexing, and usually unexplained perioperative complication: ulnar neuropathy. Perioperative ulnar neuropathy has received increased scientific attention because it accounts for one third of all nerve injury claims in the American Society of Anesthesiologists (ASA) Closed Claims Study database. In addition, these injuries may result in chronic pain or paresthesia, employment disability, catastrophic economic damages, and malpractice litigation. We will explore the current understanding of perioperative ulnar nerve dysfunction by summarizing the relevant scientific literature and information within the ASA closed-claims database, describing the epidemiologic features of perioperative nerve injuries, discussing relevant clinical investigations and recommendations for safe arm positioning during anesthesia, and reviewing the medico-legal issues inevitably intertwined with this topic, particularly the doctrine of res ipsa loquitur.