Don’t Allow your First Indicator of System Drift be a Serious Safety Event

Added on Jul 22, 2015

I bet the citizens of upstate New York are relieved that, after three weeks evading authorities, two escaped felons, both convicted murderers, are no longer a threat to the civilian population. The majority of news media focused discussion on how multiple employees of the Clinton Correctional Facility may have aided the felons in their escape. But a recent article in the New York Times described a climate at the correctional facility where corrections officers had, over many years, slowly, but increasingly, deviated from established procedures designed to ensure the effective control of their prisoners (Here is a link to the full New York Times article:

Following are few examples from the article:

  • “Prison rules forbid putting sheets across cell bars to obstruct viewing…but in practice, officers said, inmates frequently were allowed to hang sheets for lengthy periods.”

  • During hourly nightly rounds “officers must be able to see the inmate’s skin and detect breathing. But through the years, the inmates have been permitted to cover themselves with blankets, wear hooded sweatshirts over their heads and put pillows over their faces…”

  • “As a result of complaints by inmates about being awakened, guards no longer shined flashlights in their faces, and typically pointed the beam only at the shoulders.”

  • Regarding the catwalk escape route: “At one time, corrections officers regularly patrolled the catwalks, listening in on inmates’ conversations and gathering intelligence. But in recent years…officers rarely if ever went back there.”


A popular expression is that hindsight is 20/20. People reading the article may ask themselves how these corrections officers could have become so complacent. How did the leadership of the Clinton Correctional Facility allow their officers to drift so far from established policies and procedures – so far that they were now the norm (a sobering example of normalized deviance)? Part of the explanation may be that there had not been a successful escape from the prison in decades, and there had never been a break out from the maximum security section, where these two escapees resided.

This slow drift away from thorough compliance with established procedures is a threat to all organizations, including healthcare. What causes drift? Increased burden (have the procedures been modified over time to the point of being cumbersome and confusing); reduced risk awareness (have our staff lost sight of the legitimate reasons for what may seem to be time consuming steps in a process); and reduced peer influence to “do the right thing” (have our most influential staff members accepted this lower standard of performance and are all new hires taught that this is the norm).

Questions to consider:

  • 1. Are you assessing Near Miss Events to identify potential drift away from established procedures?

  • 2. Are senior leaders rounding on night shift and weekends to see if staff behaviors are consistent during off hours?

  • 3. Are we including our front line staff in the decision-making process when we look to update existing procedures or introduce new ones? They are the experts, so it makes sense that they be an integral part of the design.



Hospital Safety

In this handout from New York State Police, convicted murderers David Sweat (L) and Richard Matt are shown in this composite image. Photo courtesy of