Hierarchy and medical error: Speaking up when witnessing an error

Abstract

Objective: This review aims to identify and evaluate existing knowledge on speaking up within the context of medical hierarchy while witnessing medical error (ME). Specifically, this review explores evidence to answer the question: Within the medical hierarchy, what are the mechanisms influencing speaking up behaviours in the presence of witnessed ME? Study design: Systematic review of published articles that reported on studies relating to speaking up within the medical hierarchy. Data sources: Medline, Psychinfo and Business Source Premier. Data synthesis: The literature in this review suggested a palpable influence of the medical hierarchy upon the behaviours of both trainees and senior medical doctors. Within the context of ME this influence arguably sustains inadequate communication that contributes to compromised patient safety. Conclusion: The studies that expose hierarchies’ impact on speaking up lacked critical analysis toward the causative mechanisms influencing members of the hierarchy. Multiple studies in this review identified that seniors should encourage trainees to speak up, especially in the presence of witnessed error. It is long recognised that environments should be fostered in which trainees and seniors recognise each other's opinions, value differences and prevent an ‘us versus them’ situation from developing. Despite many efforts attempting to achieve this, the problem remains. Patients continue to be harmed, with a death rate of approximately one Boeing 737 a day (approx. 174 passengers). Trainees and seniors must speak up and listen down in the presence of witnessed error to influence a culture of patient safety and especially to reduce harm to patients.