Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up

Professor Brennan and Mr Davidson write an excellent article. Medicine does have a hierarchical culture and so active efforts are needed to facilitate open disclosure of concerns. I have two particular comments to add.

Firstly, as was mentioned, I would like to stress that we should not just be focusing on physicians, but a hierarchical culture exists within other healthcare disciplines and across these professions, a typical example being between doctors and nurses. A culture of being able to speak up when genuine concerns are held irrespective of seniority or profession needs to make its way into the ranks of our many nursing, pharmacy and allied healthcare professionals as well as doctors.

Secondly, responses to concerns raised need to be proportionate and dealt with sensitively. Avoidable errors must be prevented if at all possible, but a disproportionate response can create a hostile environment. The individual or team in question may feel resentment which blocks learning and a barrier may be formed preventing people from speaking out in future for fear of causing excessive trouble over a small issue. Of course, significant, repeated, or ‘systems’ concerns require formal reporting and thorough investigation, but often an informal discreet conversation without escalation is all that is required within the context of a ward team.

It has been said that an organisation's culture is how people act when nobody is watching. Changing culture is crucial to enabling all staff members to raise concerns. Culture is difficult to change and is rarely achieved through wielding the stick or shouting louder. In addition to formal encouragement from an organisation’s leadership, fostering respect, humility and teamwork across professions and grades, starting with interpersonal relationships on the ward or clinic team, is surely key to achieving an open constructive culture of constant learning and improvement.