Speaking Up About Patient Safety Requires an Observant Questioner and a High Index of Suspicion

Healthcare practitioners are expected to speak up about patient safety concerns to help intercept errors and avoid adverse patient outcomes. By ‘speaking up,’ we mean raising concerns for the benefit of patient safety and quality of care upon recognizing or becoming aware of a risk or a potential risk.¹ Such risks may include concerns about the safety of an order or treatment modality, a possible missed diagnosis, questionable clinical judgment, rule breaking, dangerous shortcuts, incompetence, and disrespect. Healthcare practitioners, especially frontline staff, are well positioned to observe unsafe conditions and bring them to the attention of those who can remediate them.

Speaking up is a behavioral choice under every healthcare practitioners’ control, but this is quite different than simply voicing a suggestion. A practitioner who bravely expresses a patient safety concern may cause the recipient to become defensive and set themselves up for negative repercussions. In deciding whether to speak up, the practitioner typically engages in a deliberate decision process whereby he or she considers both the positive and negative consequences, as well as the anticipated effectiveness and safety of voicing the concern.² It is a balancing act of trying to be proactive and constructive while at the same time considering the possible personal costs of speaking up. As a result, all too often, practitioners will hesitate to voice their concerns, choosing the “safe” response of silence.^3,4 On the other hand, they may speak up and be ignored or easily convinced that their concerns are unfounded.5  Silence and dismissed concerns are especially dangerous types of communication breakdowns.     

“Safe” Response of Silence

While there are numerous studies² and anecdotes that demonstrate the positive relationship between speaking up and patient safety, hesitancy to speak up is an important contributing factor in errors and adverse events.¹ Most practitioners, regardless of their position and specialty, have some experience with hesitating to voice a concern related to patient safety, even when they are aware of the risks and their moral obligation to report their concern.^1,4,6 Silence can be caused by a variety of factors, including fear of reprisal, low perceived effectiveness, low motivation, clinical factors, individual factors, normative and social pressures, lack of confidence, fear of embarrassment if wrong, a disproportionate authority gradient, and many others (Table 1). In fact, raising patient safety concerns may be perceived as a high-risk, low-benefit proposition for many practitioners.^1,7

A study conducted with nurses several years ago found that more than half had been in situations where they felt it was unsafe to speak up.⁴ Almost 1 in 5 nurses said they were in this situation at least a few times a month. One in 3 nurses had shared concerns with their coworkers about dangerous shortcuts they had observed, and only 1 in 4 had confronted a previously disrespectful colleague to share their patient safety concerns. Although nurses in the study were more likely to take their safety concerns to their managers than to speak directly to the practitioner, fewer than half of these managers followed through and spoke up about the reported safety issue; thus, taking safety concerns to a manager may not produce reliable results.

Several studies have identified the factors that influence and enable practitioners to voice their patient safety concerns (summarized in Table 1).^1-4,6,7 For example, many studies emphasized the importance of:

1. The perceived effectiveness of speaking up, such as managerial/leadership support/approachability and feedback

2. Motivation to speak up, such as a high index of suspicion, a high perceived risk, and clarity of the situation

3. Individual factors, such as job satisfaction, situational awareness, confidence, and communication skills

4. Contextual factors, such as effective teamwork and a nonhierarchical process for resolving conflicts

5. Perceived safety of speaking up, such as a psychologically safe work environment and managerial/coworker support

6. Tools and training, including a standardized rubric for speaking up (e.g., SBAR [situation, background, assessment, recommendation])

7. Measurement of the frequency, responses, and outcomes of voiced safety concerns  

Awareness of the factors that influence and enable speaking up behaviors can help leaders create a workforce who can candidly and effectively discuss their patient safety concerns without fear. The goal is to help practitioners feel comfortable and competent with being an observant questioner who speaks up about patient safety concerns, not an adaptive conformer who quietly remains silent (Table 2).⁸

_{Adapted from Tucker & Edmondson}⁸

Dismissed Concerns

When a practitioner voices a concern, there may be an explanation from competent practitioners that dispels the initial concern too quickly, before it has been given sufficient consideration. A pharmacist reassures a technician that the compounding directions are correct when questioned about an unusual volume of ingredients; a pharmacist assures a nurse that the strength of an infusion is correct when questioned about the final volume; a nurse reassures a patient that the medication is correct when questioned about its appearance; a physician convinces a pharmacist that the prescribed dose is correct when questioned because it differs from what he found during investigation. These are real, all-too-frequent examples of backing away from an initial concern that subsequently led to fatal adverse drug events. Those who questioned the patients’ care were easily convinced that others knew more than they did, particularly if the provider who was questioned had an otherwise stellar reputation.    

Is this a form of intimidation? Perhaps, but it may be more akin to a logical deference to expertise, meaning it is natural and often reasonable for people to defer final judgment to those they perceive to be more “qualified.” The person questioning the patient’s care has been easily convinced that their concern is unfounded, and the person being questioned has not perceived the voiced concern as a possible, credible patient threat. Neither the questioner nor the person being questioned possess a required element to safeguard patients: an appropriately high index of suspicion for errors. A low index of suspicion is particularly problematic in a healthcare system that is often reluctant to acknowledge human error or value the contributions from every person, regardless of rank, who interacts with the patient.

An index of suspicion is defined as “awareness and concern for potentially serious underlying and unseen injuries or illness.”⁹ Suspicion is defined as “the act or an instance of suspecting something wrong without proof or on slight evidence, or a state of mental uneasiness and uncertainty.”¹⁰ A high index of suspicion requires  consideration of a large differential so that a serious possibility is not accidentally discounted; a potential medical error should always be considered one of the possibilities. An appropriately high index of suspicion should lead a person with a concern to pursue it until it’s proven to not be a credible patient threat, even when met with opposition from experts. It should also prompt the provider to be responsive to voiced concerns and to initiate a suitable investigation to determine if there is a credible threat to the patient.

ISMP has previously discussed the need to maintain a high index of suspicion for errors in our newsletters, including an article about mindfulness, a defining characteristic of organizations with highly reliable outcomes.¹¹ Mindfulness refers to the deep and chronic sense of unease and preoccupation with failure that arises from admitting the possibility of error, even with well-designed, stable processes. People in organizations with highly reliable outcomes worry about system failures and human errors. They ask, “What will happen when an error occurs?” not “What will happen if an error occurs?” They are wary of complacency and naturally suspicious, so they expect people to speak up about any concerns they may have. Their high index of suspicion is a predominant factor in achieving laudable safety records. Furthermore, position and experience do not necessarily dictate who is an important contributor or decision maker.

To diminish unconvincing threats, healthcare needs to raise the index of suspicion for errors, always anticipating and investigating the possibility when any person, regardless of experience or position, voices concern, or when patients are not responding to treatment as anticipated. Staff need to be trained and mentored to resolve potential concerns and to trust in their own experiences to augment the expertise of others. All healthcare practitioners need to encourage, and be receptive to, practitioners who ask questions, even if they just have a sense that “something” is wrong or can’t articulate the concern well. When concerns are met with quick responses that initially appear to be “evidence” of safety (Table 3), caution is recommended. These quick responses should be viewed as “red flags” that require more reliable answers and actual proof.

Conclusion

ISMP is not discounting the fact that many complex factors influence whether healthcare practitioners speak up about patient safety concerns. We also do not discount the extraordinary courage it may take for many to step up to these conversations. However, tolerance of risk that goes unchallenged is a serious patient safety concern, and to combat that, all who interact with patients must become an observant questioner and raise their index of suspicion of errors. Healthcare practitioners need to ensure that patient safety concerns are not only raised but also properly investigated and addressed. You can be sure that those involved in serious and fatal errors wish that they had taken the opportunity to do just that.

References

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3. Morrison EW, Milliken FJ. Speaking up, remaining silent: the dynamics of voice and silence in   organizations. J Manage Stud. 2003;40(6):1353-8.
4. Maxfield D, Grenny J, Lavandero R, Groah L. The silent treatment: why safety tools and checklists aren’t enough to save lives. Report: VitalSmarts, AORN, AACN. 
5. Institute for Safe Medication Practices (ISMP). Raising the index of suspicion: red flags that represent credible threats to patient safety. ISMP Medication Safety Alert! 2012;17(15):1-3.
6. Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. Predictors of likelihood of speaking up about safety concerns in labour and delivery. BMJ Qual Saf. 2012;21(9):791-9.
7. Attree M. Factors influencing nurses’ decisions to raise concerns about care quality. J Nurs Manag. 2007;15(4):392-402.
8. Tucker AL, Edmondson AC. Why hospitals don’t learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003;45(2):55-72.
9. Pollak, AN, ed. Emergency Care and Transportation of the Sick and Injured, 10th ed. Sudbury, MA: Jones and Bartlett Publishers; 2011.
10. Merriam-Webster. Online dictionary. www.merriam-webster.com/dictionary/suspicion  
11. ISMP. Safety requires a state of mindfulness (part I). ISMP Medication Safety Alert! 2006;11(5):1-2.