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Normalization of deviance (2015)
Have you ever mentioned something that seems totally normal to you only to be greeted by surprise? Happens to me all the time when I describe something everyone at work thinks is normal. For some reason, my conversation partner's face morphs from pleasant smile to rictus of horror.
A catastrophic negligence case that the author participated in as an expert witness involved an anesthesiologist's turning off a ventilator at the request of a surgeon who wanted to take an x-ray of the patient's abdomen (Banja, 2005, pp. Pay attention to weak signals Resist the urge to be unreasonably optimistic Teach employees how to conduct emotionally uncomfortable conversations System operators need to feel safe in speaking up Realize that oversight and monitoring are never-ending People write a lot about how things like using fancier languages or techniques like TDD or agile will make your teams more productive, but having a strong engineering culture is much larger force multiplier.
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