Guest Editorial
Speak up for patient safety
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Ineffective communication is one of
the most frequently identified root
causes of sentinel events and contrib-
utes to the 400,000 deaths that occur
each year due to preventable medical
errors.1,2 Ineffective communication
includes failure of staff to speak up when they
know something is wrong that could potentially
cause harm to the patient.
While it might seem like speaking up to prevent
harm is easy, it is not. Only 49% of the 447,584
respondents to the Hospital Survey on Patient
Safety Culture felt free to question the decisions or
actions of those with more authority.3 Further, 65%
of those respondents were afraid to ask questions
when something did not seem right.3
Nurses have reported fear of retaliation,
being reprimanded, how others will respond, and
appearing incompetent as reasons for not speaking
up. Nurses have also reported that they do not
feel that anything will change as a result of their
intervention.4
This is not a new issue. A 2005 study collected
data from more than 1,700 healthcare employees,
including 1,143 nurses. The participants in the
study reported frequent observation of colleagues
making mistakes, appearing critically incompetent,
or taking dangerous shortcuts—but less than 1 in 10
spoke up about their concerns.5
This is so concerning because as nurses, we are
the patient’s advocate and we are the patient’s
voice. This communication breakdown can only be
corrected by creating a nonpunitive environment
where individuals feel empowered to speak up.
As a starting point for improving communica-
tion, the Agency for Healthcare Research and
Quality offers two free comprehensive tool kits
that can help enhance or create a culture of safe-
ty.6,7 The Comprehensive Unit-based Safety Program
DOI-10.1097/01.CCN.0000503425.05594.02
4 l Nursing2016Critical Care l Volume 11, Number 6
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
(CUSP) combines best practices and the science of
safety, and Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) is
designed to integrate teamwork principles into all
areas of a healthcare system. These two tool kits
include lecture notes, handouts, videos, and other
great resources that provide direction and support
for individuals and teams to improve communica-
tion and prevent errors.6,7
Even though it is not easy, each and every one
of us has the responsibility to speak up for patient
safety. ❖
REFERENCES
1. The Joint Commission. Sentinel event data: root cause by event
type 2004-2014. 2015. www.tsigconsulting.com/tolcam/wp-content/
uploads/2015/04/TJC-Sentinel-Event-Root_Causes_by_Event_
Type_2004-2014.pdf.
2. James JT. A new, evidence-based estimate of patient harms asso-
ciated with hospital care. J Patient Saf. 2013;9(3):122-128.
3. Agency for Healthcare Research and Quality. Hospital survey on
patient safety culture: 2016 user comparative database report. 2016.
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-
patient-safety/patientsafetyculture/hospital/2016/2016_hospitalsops_
report_pt1.pdf.
4. Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety
by hospital-based health care professionals: a literature review. BMC
Health Serv Res. 2014;14:61.
5. Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A.
Silence kills: the seven crucial conversations for healthcare. 2005.
www.silenttreatmentstudy.com/silencekills/SilenceKills.pdf.
6. Agency for Healthcare Research and Quality. CUSP toolkit.
www.ahrq.gov/professionals/education/curriculum-tools/cusptoolkit.
7. Agency for Healthcare Research and Quality. TeamSTEPPS:
strategies and tools to enhance performance and patient safety.
2016. www.ahrq.gov/professionals/education/curriculum-tools/
teamstepps.
AnneMarie Palatnik, MSN, APN, ACNS-BC
AVP of Clinical Learning & Academic Affiliations
Virtua Center for Learning, Mt. Laurel, N.J.
www.nursingcriticalcare.com