Importance of Leadership and Positive Safety Culture in Encouraging Anesthesiologists to Speak Up for Patient Safety
Communication errors are leading cause of medical incidents in healthcare. Speaking up is one of the professional accountability of healthcare staff which reduces potential harms on patients and helps to improve organizational quality related outcomes.
Introduction
Communication errors are leading cause of medical incidents in healthcare [1]. Speaking up is one of the professional accountability of healthcare staff which reduces potential harms on patients and helps to improve organizational quality related outcomes [2]. It is responsibility of every team members to speak up when they realize potential harms that going to occur during a medical intervention. When a patient at risk or vulnerable and when team members have lack of awareness; speaking up became obvious need for such situations. Since IOM report published and burden of safety events have world widely being realized by professionals and patients, professionals have spoken well enough about underlying factors of safety events with consideration of all their aspects such as endogenous (individual factors) and exogenous (general contextual factors) [3]. I believe after one and half decades, it is time to speak more about leadership to enable speaking up for patient safety and take more incentives to act towards building positive safety culture in healthcare organizations. Anaesthesiology is one of the medical fields has been influencing patient safety outcomes in healthcare organizations. Advancement in anaesthesiology and medicine has brought more responsibilities and obligations for an anaesthesiologist. One of those responsibilities require anaesthesiologist not harming patient in a various locations of healthcare organization. There are various preventable health hazards influencing morbidity and mortality in anaesthesia practice. One of them is “not prescribing appropriate anesthetic” for a patient who is going under surgery or hospitalized in a unit. As a result, safety issues may occur after application of an anesthetic and patient might be harmed unintentionally. Reasons of harm may be picking up wrong anesthetic, wrong route of application, wrong dosage, developing hypertension/hypotension, unstable heart rate, reaching to a toxic level of anesthetic (over dosage), increased intracranial pressure, causing psychiatric disorders, hyper sensitivity, drug interaction, respiratory depression and etc [4]. Furthermore, with all complications and adverse events happened, anaesthesiologist should raise their voice to contribute for safer care. Speaking up for an issue in anaesthesiology may require anaesthesiologists to be aware of list of enablers of speaking up for patient safety. Those enablers are not just essential for senior or junior anaesthesiologists, but also important and applicable for other healthcare staff [5]
Realizing the Speaking Up Problem (Noticing Issue and Necessity of Speaking Up)
Realizing the speaking up problem among healthcare team and within an organization is a positive thing that it may help to transform healthcare organization from being deaf to being transparent. Since we are considering in this article “not prescribing appropriate anesthetic”, realizing that issue whit in the team can reduce harm on a patient.
Realizing speaking up problem by an anesthesiologist is good however if team members and health organization have no psychologically safe environment that helps professionals to speak up openly; then professional may prefer to keep silent. Anesthesiologists may also prefer to stay silent if there are no active leadership within the team and existing management support to talk about concerns confidently, no transparency where healthcare team and management are not handling safety issues seriously and sweeping them under the rug, and no fairness where anesthesiologists are receiving punishment or blame due to system based errors. In an active leadership support, anesthesiologists would be delighted to identify and report relevant problems with procedures and policies, report unsafe working conditions, adverse events, close calls and speak up when they have concerns.
Having a Speaking Up Rubric
This is an aviation strategy that implemented to healthcare. Basically, an anesthesiologist is taught to question any order colleague that doesn't seem right according to relevant procedure and policies. Physicians, nurses and other frontline staff are generally trained to encourage this as a form of checks, balances, redundancy and etc. As, IHI suggests health care organization using structured techniques (such as SBAR, debriefing, critical language) to communicate more effective [6]. Those techniques are useful in and applicable to anesthesia. Thus, in an ensured horizontal communication, healthcare organization should have a strategy for how to enable anesthesiologists with other healthcare staff to speak up and challenge others. Effectiveness of this rubric should be reported, evaluated and enhanced periodically according to feed backs of staff.
Certainty about the Consequences of the Speaking Up
In one of RCT, uncertainty about the issue was mentioned twice as often as any other four hurdles of speaking up [5]. So that, anesthesiologists may still not be sure about speaking up when they have concerns. Before a medical intervention starts, active leadership of anesthesia team leader is essential. If team leader requests team members to speak up when they realize a problem and have concerns, then it will chance the atmosphere in relevant healthcare setting and encourage anesthesiologists to raise their concerns.
Having a Second Opinion or Getting Help
After realizing safety issue: having a second opinion for reducing severity of a medical incident, asking help, getting advice from other colleague and sharing training/experience may help anesthesiologists to raise their concerns and improve safety related quality outcomes [7].
Familiarity with the Individual
Despite being familiar with a colleague sometimes influences speaking up negatively, somehow it may also influence speaking up positively towards well-known colleagues. Knowing each other for a long time may help raising voices among colleagues without feeling any hesitation. Thus, familiarity with a colleague in anesthesia can be an enabler to speak up [8]. Finally, Leadership is an essential incentive of healthcare organization to achieve desired safety climate level which enables anaesthesiologists together with all medical staff to raise their concern in any healthcare setting. Patient involvement, strong leadership and supervisory, maintaining professional respect and horizontal communication in dynamic healthcare settings, having knowledge of human factors, creating shared idea of working together, having an internal norm to speak up, improving and developing assertiveness of anesthesiologists with other healthcare staff, listening and valuing of senior and junior anesthesiologists, providing training regarding to critical behaviors, and ensuring good reputation are in the hands of great leaders both in anaesthesia and others medical fields.
References
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(2012) Joint Commission Center for Transforming Healthcare Releases Targeted Solutions Tool for Hand-Off Communications. The Joint Commission 32(8).
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Reid J, Bromiley M (2012) Clinical human factors: the need to speak up to improve patient safety. 35-40.
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Nacioglu A (2016) As a critical behavior to improve quality and patient safety in health care: speaking up! Safety in Health 2: 10
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WHO Model Prescribing Information: Drugs Used in Anesthesia (2017) World Health Organization.
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Raemer DB, Kolbe M, Minehart RD, Rudolph JW, Pian- Smith MC (2016) Improving Anesthesiologists' Ability to Speak Up in the Operating Room: A Randomized Controlled Experiment of a Simulation-Based Intervention and a Qualitative Analysis of Hurdles and Enablers. 91(4): 530-539.
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PS 100 Introductions to Patient Safety, Lesson 3: A Call to Action-What YOU Can Do. Open School, Institute for Healthcare Improvement (IHI).
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Raemer DB, Kolbe M, Minehart RD, Rudolph JW, Pian- Smith MCM (2016). Improving practicing nontrainee anesthesiologists’ ability to speak up to others in the operating room: A simulation-based randomized controlled experiment of an educational intervention and a qualitative analysis of hurdles and enablers to speaking up.
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Banja JD, Craig K (2010) Speaking up in case management, part II: implementing speaking up behaviors. 15(5): 237-242.
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