If You See Something, Say Something. Silence Is Not Safe.

October 13, 2021

A teenage male presented to an ambulatory surgery center for repair of his injured right ankle. During the initial surgical time-out in the preoperative area, two team members marked his right ankle as the surgical site. They then brought him into the operating suite and placed him on his abdomen at the surgeon’s request. A repeat time-out with the entire operating team was not done. The OR nurse assisting the surgery knew that hospital policy required a time-out just before anesthesia induction, but neither the surgeon nor the CRNA initiated a time out to confirm surgical details. The OR nurse did not speak up, fearing they would be viewed as disruptive.

The marked surgical site on the right ankle was not visible to the surgeon while the teenager was in the face-down position. Consequently, the surgeon opened up the left ankle in error. During surgery on the wrong ankle, the surgeon realized that this ankle was not injured and opened up the right ankle to perform the correct surgery.

The teenager was left with two surgical sites to heal. If the OR nurse had spoken up, the teenager could have avoided the wrong-site surgery, the additional pain and the extended recovery time.

‘Speaking up’ is the raising of concerns by health care professionals for the benefit of care quality and safety once a risky or deficient action of another care team member is recognized. Deficient actions can be poor clinical judgment, a missed diagnosis or an issue during surgery.

Rule breaking and failure to follow policies also create opportunities to speak up and “stop the line” before a potential harm event occurs. Speaking up can have an immediate preventive effect on human errors and can improve technical and system deficiencies. Cultural research indicates that, in many cases, people choose to stay silent as the ‘safe’ response even when their input could be valuable in preventing harm. In health care environments, research has shown that those who are aware of a problem frequently do not speak up and when they do, they are often ignored.

An individual’s voice has important benefits for teams and organizations as well as for the person who speaks up. The frontline care team members, such as medical residents and nurses, are well positioned to observe early signs of unsafe conditions and bring them to the attention of other team members and administrators. Cultural barriers long entrenched in many health care systems are often roadblocks that prevent team members from speaking up.

Barriers to speaking up

Several cultural factors influence whether care team members speak up about safety concerns including:

  • Fear of retribution
  • Lack of psychological safety
  • A desire to avoid conveying bad news or unwelcome ideas
  • Normative and social pressures that exist in groups
  • Disproportionate authority gradients/hierarchy
  • Excessive professional courtesy
  • Deficiencies in resource or task management

The decision to speak up reflects a deliberate decision process whereby an individual considers both positive and negative consequences and the perceived efficacy and safety of voicing his or her concerns. An individual is faced with balancing an effort to be positive and constructive while at the same time being mindful of personal costs.

“Creating and maintaining a safety culture is crucial to empowering, enabling, and rewarding those who speak up in an effort to improve safety and reduce risks.”

Kristi Eldredge, Senior Risk Consultant at Constellation
How to improve your safety culture to support speaking up

There are ways your organization can improve a culture that supports speaking up:

  1. Evaluate your culture of safety using the HEAL Assessment found in the HEAL Prepare Toolkit, Unit 1-Culture. Sign in to ConstellationMutual.com and navigate to Risk Resources.
  2. Develop an action plan based on your culture of safety survey results to ensure your entire care team has the psychological safety to speak up.
  3. Utilize standard communication tools within your teams such as those found in the Best Practices and Tools section of the HEAL Prepare Toolkit, Unit 1-Culture.
  4. Develop a written chain of command policy prohibiting retribution for speaking up. Educate and train your teams on when and how to use the policy.
  5. Congratulate and celebrate individuals who speak up in support of safety.
Doing better after harm events: The HEAL Prepare Toolkit

Sign in to ConstellationMutual.com to access the HEAL Prepare Toolkit found in Risk Resources.

Constellation’s HEAL program provides healing benefits for care teams and their organizations because we truly believe that what’s good for care teams is good for business.

Constellation and HEAL are trademarks of Constellation, Inc.

Constellation and HEAL are trademarks of Constellation, Inc.

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