Face it! Intimidation presents serious
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
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.