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Violations and migrations in health care: a framework for understanding and management
  1. R Amalberti1,
  2. C Vincent2,
  3. Y Auroy3,
  4. G de Saint Maurice3
  1. 1IMASSA, Cognitive Science Department, Brétigny sur Orge, France
  2. 2Imperial College and St Mary’s Hospital, London, UK
  3. 3Percy Military Hospital, Paris, France
  1. Correspondence to:
 Professor R Amalberti
 IMASSA, Cognitive Science Department, Brétigny sur Orge 91223, France; ramalberti{at}


Violations are deliberate deviations from standard procedure. The usual reaction is to attempt to eliminate them and reprimand those concerned. However, the situation is not that simple. Firstly, violations paradoxically may be markers of high levels of safety because they need constraints and defences to exist. They may even become more frequent than errors in ultrasafe systems. Secondly, violations have both positive and negative aspects. On the one hand they occur frequently, increase system performance and individual satisfaction, are mostly limited to practices with limited safety consequences, and therefore are often tolerated or even encouraged by the hierarchy. On the other hand, extreme violations can lead to real danger or actual harm. This paper proposes a three phase model derived from Rasmussen’s theory of migration to boundaries to explain the mechanism by which the deviance occurs, stabilizes, regresses, or progresses to harm. The model suggests that violations are unavoidable because system dynamics and deviances are markers of adaptation to this dynamicity. Violations cannot be eliminated but they can be managed. Solutions are specific to each step of the model, with a mix of relaxing constraints, increasing peer control (staff), and constraining dangerous individuals.

  • medical errors
  • patient safety
  • migrations
  • safety culture
  • violations

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  • Competing interests: none declared.