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Challenger Disaster: O-rings, Normalization of Deviation and Production Pressure
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Challenger Disaster: O-rings, Normalization of Deviation and Production Pressure
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Challenger Disaster: O-rings, Normalization of Deviation and Production Pressure
Challenger Disaster: O-rings, Normalization of Deviation and Production Pressure – Randy Cornelius, DNP, CRNA, ARNP
Name
*
First
Last
Email
*
AANA Number
*
1. Normalization of deviance is characterized by what 3 characteristics?
*
A. System-based deviation, occurs only once, causes immediate incident & noticeable effect
B. Occurs repeatedly over time, human-based deviation, does not cause immediate incident or noticeable effect
C. “Murphy’s law” applicable, human and system-based deviation, occurs repeatedly
D. Human and system-based deviation, occurs once, causes immediate incident & noticeable effect.
2. Production pressure & normalization of deviance have a reciprocal relationship.
*
True
False
3. Prevention of normalization of deviance can occur by:
*
A. Paying attention to weak signals
B. Resist urge to be unreasonable optimistic
C. Realize oversight and monitoring for rule compliance are never-ending
D. Employees feeling safe to speak up & conducting emotionally difficult conversations
E. All of the above
4. Production pressure was a contributing factor to how many themes in AANA’s Foundation Transfer of Care (TOC) malpractice claims study?
*
A. 2
B. 5
C. 3
D. None
5. What are the four levels of failure that most accidents can be traced to according to Reason’s swiss cheese model?
*
A. Environment, bad luck, people, controls
B. Organization, people, work processes, chance
C. Training processes, organization, controls, equipment
D. Organization, controls, work processes, people
Δ
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