David Whitaker, Guttorm Brattebø
Improving patient safety is a very demanding and complex challenge, and despite years of numerous initiatives from many stakeholders, patients are still being hurt in health care.1 The view on avoiding unnecessary harm has changed from targeting the individual health care provider towards a broader perspective. Still, we often use the word error, which we should be more careful of using.2 Sometimes, when investigating the contributing factors of an adverse event, it appears that someone in the team already knew that something bad was about to happen before it actually resulted in harm to a patient. However, they did not raise their voice, or they did, but no one listened to them. How can this happen?
Unfortunately, there are several reasons for this situation. Most are due to certain aspects of the departmental culture, but not all. Some of these are shown in Table 1.
Table 1 Some reasons for not speaking up with corresponding statements*
- Hierarchy – “I’m only a junior doctor.”
- Respect of colleagues – “I don’t argue with an experienced consultant.”
- Professional relationships – “I don’t want to lose this friend.”
- Fear of punishment – “Speaking up may cause problems for me.”
- Avoiding conflict – “I will not start an argument.”
- Negative reputation and assessment – “I want to continue working in this team.”
- Uncertainty – “I might be wrong.”
- Conformity – “Nobody else has said anything.”
- Lack of empowerment – “This is not my responsibility.”
- Fear of embarrassment – “What if I’m wrong?”
- Concern over being misjudged; “I do care about safety, but I might be seen as quarrelsome.”
- Lack of skills – “I don’t know what to say”
- Time pressure – “I don’t have time”
- Department culture – “We don’t make such comments in our department.”
* Partly based on ref. 3-5.
The big question arising from this fact is how to invite anyone in the team to raise their voice if they see something they think may threaten a patient’s safety. It has been demonstrated that if the team leader explicitly invites comments and input from the team, this increases the likelihood for a given team member to raise their concerns.
So, what can we do? The WHO safe surgery checklist is well-known and mandatory in many countries. One part of this is that everyone in the room should tell who they are, thereby forcing everybody to say something and hear their own voice.
The European Board of Anaesthesiology (EBA) has recommended that staff speak up if they believe safety is compromised.6 A beneficial technique which may be useful is “to be curious” in a non-threatening way about what you are concerned about, pretending you are not very knowledgeable.7 For example, ask, “Why has this syringe no label like the ones used in the OR?” or “I wonder why you are doing that?”
The so-called DESC Script8 is another way of making one heard by trying to manage and resolve a conflict. It consists of four steps: 1 (D): Describe the specific situation or behaviour and provide concrete data; 2 (E): Express how the situation makes you feel and what your concerns are; 3 (S): Suggest other alternatives and seek agreement; and 4 (C): Try to state the consequences in terms of impact on established team goals and strive for consensus.
Encouraging people to speak up is useless if other group members are not prepared and taught to “listen up”. If a junior staff member appears to be curious, this may be an alert that something unsafe is about to happen and eventually harm the patient. A culture of “listening up” means always being aware of what could be a subtle message and not responding negatively, thereby reinforcing the reasons suggested in Table 1. Understanding this is a crucial group activity and particularly valuable when group members are inexperienced at working with each other or unfamiliar with the procedure or the environment they are working in.
The person listening up must then act proportionately, stopping or pausing the procedure or encouraging and supporting further detailed discussion of the possible safety issue. This could be seen as a cycle: Speak up > Listen up > Act > Review.
Due to the barriers to speaking up that must be overcome, this could be demonstrated, practised, or rehearsed in the clinical workplace. For example, two senior colleagues working together could set this up, and during a procedure, one could question the other as to why they were doing a particular thing. The other colleague could reply by welcoming the inquiry, showing they were not offended, and explaining their actions. This will show others how it can be done and thereby, reduce the threshold for others to raise issues within a team. It would also have a secondary effect on people explaining what they are doing, teaching, and explaining the procedure. If this becomes a regular element of clinical practice, the threshold for raising concerns would be lowered, and the familiarity of being ready to listen up increased.
From the top down, hospital boards and management should create a speaking-up culture at the workplace, supporting health and well-being.9 It is essential that managers should also be taught “Listening up” and listen and respond with curiosity rather than defensiveness. This applies to dealing with staff’s workplace concerns up to the managerial level of responding correctly to “whistleblowing”. Because of the high threshold for speaking up in these circumstances, any occasion should be listened to as if they were the “canary in the mine”. Sadly, there are many high-profile examples where failure to do this, often in a misguided way of trying to protect the organisation’s reputation, has cost the patients dearly.10
Note: The topics covered in this text, and many more patient safety-related issues, were published in the EJA issue on the ten anniversary of the Helsinki declaration on patient safety in anaesthesia: Preckel B, Staender S, Arnal D, et al. Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects. Eur J Anaesthesiol. 2020; 37:521-610.
- Wears R, Sutcliffe K. Still not safe: patient safety and the middle-managing of American medicine. 1st Edition. New York, Oxford University Press, 2020.
- Brattebø G, Bergström J, Neuhaus C. What’s in a name? On the nuance of language in patient safety. Br J Anaesth. 2019; 123:534-6.
- Raemer DB, Kolbe M, Minehart RD, Rudolph JW, Pian-Smith MC. Improving anesthesiologists’ ability to speak up in the operating room: a randomised controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers. Acad Med 2016; 91:530-9.
- Pian-Smith MC, Simon R, Minehart RD, et al. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc 2009; 4:84-91.
- Voogt JJ, Kars MC, van Rensen ELJ, Schneider MME, Noordegraaf M, van der Schaaf MF. Why medical residents do (and don’t) speak up about organisational barriers and opportunities to improve the quality of care. Acad Med 2019; Oct 1. doi: 10.1097/ACM.0000000000003014
- Cooper JB, Caplan RA, Gaba DM. APSF workshop engages the audience in communication skills and drills. APSF Newsletter 2013; 27: No. 3. https://www.apsf.org/article/apsf-workshop-engages-audience-in-communication-skills-and-drills/
- Findings, conclusions and essential actions from the independent review of maternity services at The Shrewsbury Telford Hospital NHS Trust. https://www.ockendenmaternityreview.org.uk/wp-content/uploads/2022/03/FINAL_INDEPENDENT_MATERNITY_REVIEW_OF_MATERNITY_SERVICES_REPORT.pdf
- Embedding a healthy speaking up culture. NHS Employers 2023. https://www.nhsemployers.org/articles/embedding-healthy-speaking-culture