Speak up!

Five minute teaching 003

Author: Chris Nickson
Reviewer: Irma Bilgrami

As health care professionals we have an obligation to speak up about our concerns before a critical event reaches a patient, so that the plan or action can be corrected before it is too late. Speaking up is absolutely vital to maintaining patient safety in critical care settings, yet it often does not occur.

Speaking up requires courage and skill, but is essential. We must always advocate for our patients and never leave thinking ‘I should have said something!’

Q1. What is speaking up?

Speaking up is the act of expressing concern about a plan or course of action before an error of commission or omission occurs. Typically it involves a person in a non-dominant or follower role communicating with a person in a dominant or leader role.

Examples include a co-pilot speaking up to a pilot to prevent crashing into a mountain, or a nurse or junior doctor speaking up to a consultant who is about to make a drug error.

Q2. Is NOT speaking up a big problem?


Failure to speak up is a big problem for two reasons:

  • it is common
  • patients can be harmed as a result

For example, the 2010 Silent Treatment study of 6,500 nurses and nurse managers in the USA found that 84% of respondents reported >10% of their colleagues taking dangerous shortcuts and 26% said these shortcuts had actually harmed patients. However, despite these risks, only 17% shared their concerns with the colleague in question. Doctors are unlikely to be any better.

Speaking up is important as it can help avoid patient care errors or assist in recovering from them. The frequency of speaking up also predicts technical team performance and helps gauge the safety and transparency of an organisation.

Q3. How can we speak up effectively?

A useful way to speak up effectively is to use a graded assertiveness approach. There are a few different ways of doing this, and one option is the PACE approach. This was developed by a chap called Dr Bresco as a way of dealing with the co-pilot’s “Catch 22”: “You are damned if you ignore the Captain’s mistakes and you are damned if you do something about them.”

This is what PACE stands for (there are a few variations):

  • Probe – e.g. “I don’t understand why…”
  • Alert – e.g. “I’m concerned that that will…”
  • Challenge -e.g. “This approach risks harming the patient because…”
  • Emergency – e.g. “Stop. I will get help from the consultant to make we don’t make a mistake”

This approach allows the junior person to remain respectful and avoid any unnecessary conflict or triggering defensiveness. The senior person has a chance to correct any misunderstandings or mistakes, and save face. However, if the junior person’s concerns are not dealt with sensibly, the junior person can escalate in a stepwise fashion to ensure harm is not caused.

It is important that the questioning is not adversarial, and that appropriate tone of voice and body language is used.

The onus is on leaders to recognise the value of speaking up, encourage it and ensure that there are no recriminations for those who do speak up.

If you prefer other approaches to speaking up that’s fine, just do it!

Q4. Imagine you are a junior doctor and you see a more senior registrar about to give a 40kg frail elderly lady 300mg of propofol for procedural sedation for a Colles fracture reduction. How could you approach this?

Using PACE, this might be your approach:

  • Probe – “I don’t understand why you are going to give 300mg of propofol?”
    if no sensible response or correction, then escalate to…
  • Alert – “I think that the dose is too big, it will drop the patient’s blood pressure too much.”
    if no sensible response or correction, then escalate to…
  • Challenge -“Giving 300mg of propofol is wrong, we will put the patient at risk of life-threatening hypotension”
    if no sensible response or correction, then escalate to…
  • Emergency – “Stop, do not give the propofol. I will get help from the Consultant to make sure we don’t make a serious error.”


  • American Association of Critical-Care Nurses. The silent treatment: why safety tools and checklists aren’t enough to save lives. Aliso Viejo (CA): The Association. Available from: http://www.silenttreatmentstudy.com
  • 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 Feb 8;14:61. doi: 10.1186/1472-6963-14-61. PubMed PMID: 24507747; PubMed Central PMCID: PMC4016383.
  • Speaking up (LITFL Critical Care Compendium)
  • Srivastava R. Speaking up–when doctors navigate medical hierarchy. N Engl J Med. 2013 Jan 24;368(4):302-5. doi: 10.1056/NEJMp1212410. PubMed PMID: 23343060. [Free Full Text]

2 comments to “Speak up!”
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