Speak Up for Patient Safety

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“High-reliability” has been a buzzphrase in the healthcare industry for the last several years, but this safety movement is still gaining momentum. Many healthcare systems around the United States, including clinics, are taking steps to become high-reliability organizations. The high-reliability movement is largely based on safety principles developed in the nuclear and airline industries, where every employee is accountable for safety. These high-risk industries ingrain workplace safety into their culture primarily because, if an error occurs, the employee is likely to get injured – i.e., the pilot goes down with the plane. The stark difference in healthcare is that, if an error occurs, the care team goes home at the end of the day; usually it is the patient that suffers the result.

One of the guiding principles of high-reliability is to have a preoccupation with failure. Focusing on all errors, irrespective of whether they have caused patient harm, often highlights larger system failures.

While there are many high-reliability processes and tools to deploy to help make healthcare safer, the most effective is to create a culture where healthcare teams feel safe to speak up. If members of a healthcare team are fearful to speak up, it is nearly impossible to maintain an accurate perception of safety in your setting.

Many investigations following sentinel events show that one or more team members noticed something concerning but failed to act, either because they were scared to speak up or they assumed someone else would address the problem. While it might seem like speaking up to prevent harm is easy, it is not. In 2016, the Agency for Healthcare Research and Quality (AHRQ) found that only 49% of 447,584 respondents to their Hospital Survey on Patient Safety Culture felt that they were free to question decisions or actions of individuals with higher authority. Furthermore, 65% of those respondents were afraid to ask questions when something did not seem right.

How do providers change this fear-based culture? It starts with clinic leadership and physicians providing all members of their healthcare team the tools to speak up. These tools can be as simple as creating catchphrases such as “I have a concern” or “CUS” ( I’m concerned, uncomfortable, stop). When these catchphrases are used by anyone on the team, everyone takes a pause to address the concern before moving forward. Teaching caregivers how to address a concern creates the expectation that they will do so.

It is just as important to address how physicians respond when a team member speaks up. Physicians should try to convey to the individual that they have heard the concerns, thought about them, and weighed the pros and cons of action or inaction. Importantly, the physician should always acknowledge and thank the team member for speaking up, no matter how trivial the issue may be. Positive reinforcement from leaders and physicians is the only way this safety culture will be embraced by staff. Reprimanding or shaming an individual for stopping the line, even if they turn out to be wrong, could prevent them from speaking up next time… when they may be right. As Dr. Eve Lowenstein put it, “An awareness of what we do not know can be more important than what we do know.”

This safety culture can be fostered in any setting, start by anonymously surveying staff to see how comfortable they are with speaking up. Solicit what immediate concerns they have around patient safety? What do they need to perform their job safely? Determine what needs exist and then move toward prevention, or in other words, from “what did go wrong to what could go wrong.”