The Silent Treatment
VitalSmarts, AORN, & AACN present:
Why Safety Tools and Checklists Aren’t Enough to Save Lives
David Maxfield, Joseph Grenny, Ramón Lavandero, and Linda Groah
Silence Kills was conducted immediately before AACN’s national standards for healthy work environments were released10. It identified seven concerns that often go undiscussed and contribute to avoidable medical errors. It linked the ability of health professionals to discuss emotionally and politically risky topics in a healthcare setting to key results like patient safety, quality of care, and nursing turnover, among others. The Silent Treatment shows how nurses’ failure to speak up when risks are known ...view middle of the document...
” Poor communication is deadly, especially in critical care settings1,2. When communication breaks down in intensive care units (ICU) and operating rooms, the result is catastrophic harm3,4,5,6 and even death7,8. The study examines an especially dangerous kind of communication breakdown: risks that are known but not discussed, or “undiscussables.” It builds on findings from research conducted in 2005 by the American Association of Critical-Care Nurses (AACN) and VitalSmarts9 as documented in the research Silence Kills: The Seven Crucial Conversations for Healthcare.
When communication breaks down, it breaks down in two very different ways. Business theorist, Chris Argyris ,groups these breakdowns into two categories: honest mistakes and undisscussables11. Each category has a different cause, produces a different range of outcomes, and requires different solutions. Honest mistakes include accidental or unintentional slips and errors—for example: poor handwriting, confusing labels, difficult accents, competing tasks, language barriers, distractions, etc. Somehow, the baton is dropped during handoffs between shifts, departments, specialties, or caregivers. Psychologist, James Reason, describes these honest mistakes as the human equivalent of gravity12— they are inevitable. So they must be guarded against. When healthcare organizations invest in improving communication, they usually focus on reducing these
honest mistakes. They implement handoff protocols, checklists, computerized order entry systems, automated medication dispensing systems, and other similar solutions all aimed at doing away with these unintentional slips and errors. These improvements are absolutely essential but they fail to address the second category of breakdowns, the undiscussables. When people know of risks and do not speak up, the breakdown feels more intentional. Someone knows, or strongly suspects, that something is wrong, but chooses to ignore or avoid it. He or she may attempt to speak up but quits when faced with resistance. It’s not a slip or error; it’s a calculated decision to avoid or back down from the conversation. Information-based solutions like protocols, checklists, and systems don’t do much to solve the breakdowns in this second category. The literature on organizational silence13,14 suggests that solving undiscussables will require deeper changes to cultural practices, social norms, and personal skills. The Silent Treatment examines these calculated decisions to not speak up. It tracks how risks that are known but not discussed undermine many current safety tools. It documents the frequency and impacts of these discussions, and shows how individuals and organizations can make undiscussables discussable.
to three concerns: dangerous shortcuts, incompetence, and disrespect. Respondents were asked how often they face these concerns within their immediate work group, how they handle these concerns, and how these concerns have impacted...