The Elephant in the Room About Speaking Up for Patient Safety

By Marjorie Stiegler on October 6, 2014 in Communication, Error, Omission Bias
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I’ve been part of many workshop programs aimed at improving communication among team members in healthcare.  Among operating room teams, that often seems to revolve around “speaking up”.   After an event occurs, it is almost unfathomable that a team member possessed information that could have prevented the problem, but simply didn’t speak up.

This seems unacceptable to the rest of the team, and based on personal experience with hundreds of folks who didn’t speak up, it is also gut-wrenching to the person who was silent.

Without exception, people say that if they knew the harm that would be caused by their hesitation, they would have absolutely put aside whatever held them back and they would have spoken up.  This is not really surprising – most physicians, nurses, and other healthcare providers do indeed have the patients’ best interest at heart.

What is surprising is the near-universal experience of not speaking up.  After we’ve heard so much from TeamSTEPPS and other programs, and after folks have gone to such great lengths to establish communication rubrics (such as SBAR, CUS, and the 2 Challenge Rule) that support speaking up, nearly 1/3  all communications within the OR fail in their purpose.   Highly represented in these failures are communications that are too late to be actionable.  Not represented at all, but certainly a big contributor to medical error each year, are communications that simply do not occur at all.

It would seem natural that if we want to avoid harm to our patients we would be motivated to speak up often and early. So why is that we fail to speak up in a timely manner or at all?

It turns out that there are a variety of reasons why nurses and doctors do not speak up.  These seem to be universal – audiences across the United States in many disciplines offer these same explanations again and again.  (Let me be clear that I am not proposing that this excuses the behavior, but better understanding may lead to better solutions.)

  1. Assumed hierarchy
  2. Fear of embarrassment of self or others
  3. Fear of being wrong
  4. Concern for reputation
  5. Fear of retribution
  6. Jeopardizing an ongoing relationship
  7. Natural avoidance of conflict
  8. High value placed on experience of another team member

If we inspect this list closely, we can see that most items revolve around trust.   For some, we do not trust other people to welcome our intentions, but instead fear retribution, embarrassment, or loss of a good relationship.  Or, we don’t speak up because we don’t trust ourselves – we assume the more experienced person actually is right.    In all cases, our hesitation or complete omission to speak up for patient safety concerns are tied into our own psychology and have nothing at all to do with patients.

Here’s an example – a story I was told by a colleague from one of the most prestigious academic centers in the US:

A CRNA (nurse anesthetist) was caring for a healthy ten year old undergoing a laparoscopic abdominal surgery, together with a surgeon, anesthesiologist,  and OR nurse he knew well.  The CRNA was known to be extremely prickly in personality, sometimes yelling at staff or belittling them if they asked a “stupid question”.  He was also thought to be clinically very competent.  On this particular day, some intense family troubles that had been causing him many nights of lost sleep finally caught up and the CRNA fell asleep in the operating room.  (I am not excusing this – simply providing the context. Obviously, this is unacceptable.)  The OR nurse noticed that he was asleep, but feared waking him because of his quick temper.   The surgeon couldn’t see him, but had asked him questions that went unanswered, but the surgeon didn’t persist because he felt the CRNA was competent and didn’t want to offend him, thereby jeopardizing their good working relationship.  No one thought to contact the supervising anesthesiologist, who was directing the care of four operating rooms and CRNAs at the time.  The surgeon caused a pneumothorax (not entirely uncommon), which became serious and ultimately caused the patient to arrest.  This went unnoticed by the CRNA, who would normally be the clinician to first detect it due to increased airway pressures, loss of respiratory tidal volume, decreasing oxygen saturation, and low blood pressure.   By the time the CRNA awoke and realized what was happening, it was too late to revive the patient, who ultimately died.

Of course, after the fact, all parties involved were filled with tremendous guilt and regret.  Would the OR nurse have happily welcomed a temper tantrum, if she had known it would save this child’s life?  Would the surgeon have risked offending his frequent co-worker, if he had known it would save this child’s life?  Would the CRNA have discussed his problems with his supervisors and requested some time away from clinical duty because he might not be cognitively at his best?  YES, YES, and YES.   Did any of those professionals hold the patient with little regard, unconcerned for the life in their hands that day?  I doubt it.  I suspect they cared very much for that boy and are perhaps still suffering from the emotional toll of the mistake of not speaking up.   As well, I’ll bet the anesthesiologist is regretting that he did not realize what the CRNA was going through, and advocated for him to be relieved from duty.

Can we look at this problem starkly, exposing it for what it is, and simply call ourselves on it?  It is time to get over our own reasons for failing to communicate, and truly put patients first.   Speaking up, and welcoming the intentions of those who are speaking up, will change organizational cultures over time.   It will also save us from errors and patient harm.   I know that today, if it seems to anyone that I am about to make a misstep, I want my team to speak up and stop me, even if they are wrong.  I don’t want to hurt people, and I don’t want to lose my job, and I don’t want to be sued.   I need my team to support me in that way, and I thank them for doing so every time.  As a result, I believe they are even more forthcoming, and I’m fostering my own microcosm of safety culture.

When someone speaks up and challenges you, do you welcome it and thank them? Or does ego and defensiveness get in the way?  Leave me a comment or send me an email.  I’d love to hear from you.

Credit: Image from depositphotos.com 

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