Susan has worked in your office as an orthodontic assistant for over 15 years. She joined your practice as soon as she graduated from her dental assisting program and has been invaluable in training your other chair-side assistants. Because she always emphasizes the positive with a smile and has a light touch in all procedures regardless of their difficulty, you are grateful to have her. But recently you noticed that a bracket table had tinges of blood on its surface after she cleared the chair for your next patient. And yesterday, a patient pointed out a trace of green enamel conditioner that was left behind after you completed a full bonding procedure. Strange, you thought. Susan has always been so meticulous about cleanliness. Recalling that Susan had prioritized punctuality during your last staff meeting, you wonder whether she is shortcutting the disinfection protocol in favor of increased production.

As you complete the day’s laboratory prescriptions after a particularly busy day, you casually ask Joan, another of your seasoned assistants, whether the staff feels undue pressure to shuffle patients in and out of the operatory at peak treatment times. Remaining apolitical, she smiles in a coy way and replies, “It certainly can get hectic around here.” When you ask her whether she feels that the pressure to accelerate patient flow might be compromising standards, she just shrugs her shoulders. She has always been noncommittal, you concede to yourself.

Normalization of deviance is “a gradual process in which unacceptable practice standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.” There is a similarity among normalization of deviance in industry, government, and health care. For example, the explosion of the Challenger space shuttle in 1986 was caused in part by management’s repeated disregard of imperfect O-ring seals that eventually failed, causing a rocket booster to explode. This resulted in the catastrophic death of all 7 crew members after only a minute into the flight.

The more frequent the deviant behavior, the more accepted it becomes. Although external observers might easily recognize the behavior as aberrant, those who practice it do not realize it until they assess their action retrospectively. In normalization of deviance in health care, workers often justify a deviation of practice as acceptable—sometimes even essential—to patient care. Consider unsafe hygiene procedures in a dental setting, such as inadequate hand washing or failure to change gloves. A practitioner might justify compromise of these essential precautions during a harried afternoon to save time. The orthodontist who cuts down tooth structure in youngsters to create the appearance of aligned mandibular incisors—rather than move the teeth—is another example. An orthodontist’s disregard of the need for periodontal care in the treatment of susceptible adults might not exacerbate attachment loss in all patients, but even 1 patient who develops a furcation involvement as a consequence of tooth movement is too many.

Deviations of accepted practice are nonverbally condoned when leadership figures accept those practices without objecting to them. And junior staff members might remain unsure of the acceptability of the deviant behavior if they are not challenged as soon as the deviation is observed. We are the role models for our staff.

Your directive to Susan must be direct and uncompromising. Regardless of the burden of oppressive time demands, established sterilization and disinfection procedures must be consummated before every patient is seated. Your tenacity is essential not only for preventing extinction of established protocol, but also for protecting the vulnerability of patients who trust their welfare to you. That’s nonmaleficence, and as long as you practice, that responsibility remains yours.