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Face it! Intimidation presents serious safety issues

From the November 13, 2002 issue

It should come as no surprise that physicians who use intimidation to dissuade individuals who are questioning the safety of their orders create serious safety issues in healthcare. Unfortunately, it happens more frequently than most are willing to admit, in both subtle ways as well as clearly abusive forms of communication. Here's just one recent example, which may sound painfully similar to others that likely happen every day in healthcare organizations.

An oncologist wrote an order for fluorouracil 4,100 mg to be administered over 12 hours for 8 doses (a total of four days). The pharmacist who received the order was new to the profession, but she immediately recognized a potential dosing error and contacted the prescriber. The physician was unhappy about the call, but he cited the review article he had used for reference to substantiate the dose (Case EA, Stehman FB. Multimodal therapy in the treatment of carcinoma of the uterine cervix. Oncology Spectrums 2001;2:323-8). The pharmacist investigated further and found that the dose in the review article (listed in the top right-hand column on page 325) indeed stated "4 g/m2 of body surface area every 24 hours for 4 days." But when she calculated the patient's dose (based on a body surface area of 2.05 square meters), she still felt it was unsafe and contacted the oncologist again. Incredibly, the oncologist became verbally abusive and insisted that the pharmacist dispense the original dose. Fortunately, the pharmacist retrieved the original articles referenced in the review and found that the dose was stated clearly as 4 g/m2 for an entire course of therapy. The authors of the review article had inadvertently written the total four-day dose as the daily dose for four consecutive days (the journal has been contacted for correction). When the pharmacist again contacted the oncologist, his anger about being questioned appeared to cloud his ability to think clearly and he continued to demand that the original order be followed! A pharmacy manager then contacted the chief of medicine, who voided the oncologist's orders.

Certainly, the new pharmacist should be congratulated for taking a firm stand when it came to patient safety. Likewise, the hospital should be congratulated for having a mechanism in place for the pharmacist to follow when the safety of medication use is in conflict. But what about the physician's behavior? It's not uncommon for errors to begin with physician misinterpretation of published information, ambiguous statements in the reference, or even misprints in otherwise reliable references. Yet, the intimidation factor is a real barrier to patient safety because it adversely affects the ability of others to detect potential mistakes, point them out, and have them corrected before they reach the patient.

Intimidating and abusive behavior should never be tolerated in healthcare. Such intolerance should not be misconstrued to represent punishment for those who make errors. The issue is not whether such behavior resulted in an error, rather that it is egregious and unacceptable under any circumstances. It promotes stress, job dissatisfaction, employee turnover, resentment, and miscommunication, all of which can only result in poor outcomes for patients. As such, the topic should be covered fully in policies and bylaws, discussed during all staff orientation (including physician orientation) and addressed immediately if it occurs.

In other complex industries with better safety records than healthcare, all uncertainty about safety is presumed to be a serious problem without putting the person who expresses the concern on the defensive to prove he is right.1 Simply put, if someone thinks it may be unsafe, it is considered unsafe. Equally important, these highly reliable industries follow a "two challenge rule" where the person who is concerned about safety communicates the problem and its rationale twice. If no resolution occurs, the matter is automatically referred to others for resolution. This review process does not imply that the person concerned about safety "wins," it just means that the situation must be reviewed quickly by at least one other person before a final decision is made. It would be wise to follow this example to help counteract intimidation.

Reference 1: Gifford BJ, Morey J, Risser D, et al. Enhancing patient safety through teamwork training. Journal Healthcare Risk Management. 2001; 21(4):57-65.
Editor's note: We thank John Gosbee, MD, MS, National Center for Patient Safety, US Department of Veterans Affairs, for his contribution to this article.
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