Drift Toward Failure Concept

     In all industries, there is a fundamental trade-off between production and safety. When accidents are infrequent occurrences (as they generally are in systems such as health care where accidents can have high consequences), production goals begin to dominate over safety goals. This is partly because improvements in production are often easily measurable and rewarded by the organization, whereas improvements in safety are indicated by the absence of outcomes, which are hard to measure and reward. It is only after a bad accident or a frightening near-miss that safety becomes uppermost in the minds of those who manage an organization.

     The stereotypical pattern of "drift toward failure" can be seen in hindsight after nearly every accident. Managers of an organization realize that production and safety both are necessary long-term goals. Nevertheless, in the short term, line managers are forced on a daily basis to choose whether or not to cut safety corners in order to meet operational demands (e.g., should we assign 3 patients to one nurse in the SICU today because we are short-staffed or should we cancel scheduled surgeries in order to maintain a ratio of 2 patients to a nurse?). For the most part, such short-cuts bring no bad effects, and so become an habitual part of routine work practices (even though they don’t tend to be reflected in official "standing operating procedures"). As time passes, the safety margin is gradually diminished during event-free periods until an accident occurs.

     Acknowledgment: Parts taken directly from Reason (1997). Managing the Risks of Organizational Accidents. Ashgate Publishing Company, pp. 4-5.