Acronym
Explanation
Example
Acronym
Statement
Example
“I am concerned the dose you ordered is incorrect.”
“Your conversations during induction of anesthesia have been loud and distracting.”
C oncerned
I am concerned!
Describe
The details of the situation
“I am uncomfortable with administering this dose.”
“It makes me feel like what I am doing is not important to you, and I am concerned that I will not be heard if I need assistance with the patient.” “It would be safer if there is less noise during induction in the future.”
U ncomfortable
I am uncomfortable!
Explain
Feelings/concerns about the situation
“I believe this dose is unsafe for the patient.”
S cared
This is a safety issue!
Suggest
Alternative options/actions
Table 1A: CUS Tool
“Should conversation be necessary, it should be done so quietly or in another space.”
Consensus
State the concrete plan/goals agreed upon
Effective communication plays a crucial role in preventing medical errors, and understanding the different levels of communication in medical settings is important. Provider-to- provider communication represents the initial stage of communication about patient safety. Intervening upon witnessing a safety concern can prevent adverse events. However, several barriers impede effective communication among healthcare providers. The provider hierarchy, particularly between nurses and physicians, can hinder communication. Even among physicians, residents and students may hesitate to speak up to attending physicians for fear of appearing foolish or facing reprimand. The relationship between the individual witnessing a safety concern and the person responsible for the problematic activity also impacts effective communication. The likelihood of raising a safety concern depends on the approachability and receptiveness to feedback of the other person. A provider who brings up a safety concern is more likely to continue doing so if their feedback is appreciated rather than met with anger or dismissal. Gender and cultural differences can further impact communication effectiveness. Additionally, the institutional culture surrounding safety events significantly influences these interactions. A variety of tools have been specifically developed for hospitals and individuals to facilitate communication regarding safety concerns. One notable example is T eam S trategies & T ools to E nhance P erformance and P atient S afety (TeamSTEPPS), which was created by the Agency for Healthcare Research and
Quality. TeamSTEPPS provides a comprehensive framework for communication within healthcare teams. It emphasizes the importance of leadership, active situation monitoring, and clear communication to enhance the performance of healthcare teams. The framework also promotes the use of communication tools to facilitate effective communication among team members. These tools include SBAR ( S ituation, B ackground, A ssessment, R ecommendation, and R equest), which is used to convey critical information about a patient requiring immediate attention. CUS (I am C oncerned! I am U ncomfortable! This is a S afety issue!) is another tool that encourages assertive communication. DESC ( D escribe the situation, E xpress your concerns, S uggest alternatives, C onsequences, and strive for C onsensus) is a communication method that assists in addressing complex situations. The framework also highlights the significance of closed-loop communication, ensuring that the information understood by the receiver aligns with the intended message of the sender. Above all, TeamSTEPPS empowers all team members to “stop the line” if they observe a safety breach through the implementation of the “two-challenge rule.” This rule encourages team members to voice their concerns at least twice to ensure they have been heard. If the safety issue remains unaddressed, the team member is encouraged to escalate the concern through the chain of command until it is resolved. Escalating safety concerns is a crucial aspect of effective patient safety communication. The way hospital leaders and administrative staff handle these concerns not only impacts
Table 1B: DESC Tool
patient safety but also influences the willingness of healthcare providers to communicate future safety concerns. Organizations that value and prioritize the raising of safety concerns are known as high-reliability organizations (HROs). HROs foster a culture of open communication where safety concerns are encouraged, taken seriously, and thoroughly investigated. They recognize the fallibility of human beings and the imperfect nature of healthcare systems, and employ human factors engineering to improve these systems and prevent future harm. These organizations prioritize psychological safety and a just culture. Psychological safety, a concept developed by Amy Edmondson at Harvard Business School, refers to an environment where individuals feel comfortable speaking up without fear of reprisal. In teams that promote psychological safety, concerns are welcomed, and those who raise them are praised. The team works collectively to address the identified issues. Similarly, the concept of a just culture, developed by David Marx and expanded upon by James Reason, emphasizes evaluating clinicians’ actions when errors occur. It distinguishes between conscious errors, reckless behavior, reflexes of competence, and simple human error. Negligence, impaired practices, and competence issues are addressed, while clinicians involved in unintended human errors, often referred to as the “second victims,” are supported and comforted.
In contrast, production-focused organizations are more inclined to dismiss safety concerns or attribute blame to individuals rather than identifying systemic problems. These environments tend to adopt a “blame and shame” approach, which can discourage healthcare providers from communicating safety concerns to their colleagues or leaders. By promoting a culture of safety and embracing principles such as psychological safety and just culture, HROs create an environment where effective communication about safety concerns is valued, encouraged, and acted upon, leading to improved patient safety outcomes. Effective reporting systems play a crucial role in patient safety communication. There is ongoing debate in the literature regarding the effectiveness of voluntary reporting versus mandatory reporting. However, an ideal reporting system should be easy to use, maintain confidentiality, and offer the option of anonymity. Such a system should also ensure that relevant quality and safety leaders are promptly notified of the reported safety concerns. Safety leaders who aim to promote psychological safety within their organizations should prioritize transparency by sharing pertinent safety events with other healthcare providers. Maintaining peer review protection is essential for all communication related to adverse events, medical errors, and evaluations of
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COMMUNICATING ABOUT PATIENT SAFETY 45
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