If you shut the door to all errors, truth will be shut out. Rabindranath Tagore

Medical care is routinely delivered by a team of healthcare professionals working together. When researchers analyze the chain of events that ended up harming a patient, they find that often someone knew that something was wrong, but didn’t have the courage to speak up; or they spoke up but weren’t heard.

While nurses and doctors are usually well trained in the technical aspects of their individual jobs, they typically receive no training in how to work together, even though they have to do this all the time. This can cause communication to break down, especially when senior surgeons act as “prima donnas” and throw temper tantrums, resulting in a dysfunctional atmosphere of fear, where juniors are too scared to open their mouth, even when they see mistakes being made under their nose.

These “authority gradients” mar communication. This is why medical staff should use a structured technique called SBAR, which is designed to convey information crisply, in an organized manner.

* Situation = A concise statement of the problem. What is going on at present?

* Background = Pertinent information related to the situation. What has happened so far?

* Assessment = Your analysis. What did you find?

* Recommendation = The action you are requesting. What do you want your senior to do?

The SBAR technique creates a shared mental communication model that ensures the nurse and physician remains on the same page throughout the conversation.

Working towards a common goal Doctors need to work together with assistants and nurses as a team. Healthy medical teams learn to maintain “situational awareness”, so they don’t lose sight of the big picture, even during crises. The model which a lot of hospitals have adapted from the aviation industry is that of Crew Resource Management (CRM), which encourages effective teamwork and communication, to help prevent errors, and allow each team member to act as a safety net. Openness allows the free flow of information, so that members coordinate and cooperate with each other to achieve a common goal.

Team events like Briefs, Huddles and Debriefs have been shown to improve patient safety.

* Brief-A brief is a short meeting to discuss essential information such as the clinical status of the patient; team roles; goals and barriers, and issues affecting team operations. The brief allows the team leader to explain what is going to happen, cover contingencies, get input from each member of the team (including the patient), and ensure that each team member knows his or her roles and responsibilities. An excellent example of a tool used routinely before surgery for briefs is the WHO surgical safety checklist, that can be found at http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html

* Huddle

- A huddle or information update can be called by any team member at any time, to deal with new issues, added complexities, unusual circumstances, or any need to adapt the earlier plan.

* Debrief

- A debrief recounts what happened during the event; extracts lessons learned; and adapts the current plan in order to incorporate these lessons.

The strategies

Strategies to improve communication and information exchange include the following:

* Using assertive language, to ensure the message has been properly transmitted. This is especially important when a junior nurse is pointing out a problem to the senior surgeon, for example. Doctors need to encourage their assistants to speak up, in order to keep their patients safe. Effective assertion is persistent, polite, timely, and clear and solution focused. For example, if a junior feels she is not being heard, she can escalate her concerns by using “CUS” as a guideline - “I’m Concerned,” “I’m Uncomfortable,” “This is a Safety issue”.

* Call-out, which is used to communicate critical information during an emergency. For example , during a cardiac arrest , the nurse “calls-out” what medication she is giving to the patient.

* Check-back, which is used to close the loop of communication, and verify information. An example of a check-back would be when the laboratory phones to convey a critical laboratory result, and the nurse repeats all the information back to verify that it was correct.

* Handoff, which allows for the exchange of necessary information during transitions in care. An example of this would be the report from the ER (Emergency Room) to the ward when the patient is being admitted.

The Agency for Healthcare Research and Quality (AHRQ) in the USA has developed the TeamSTEPPS® evidence-based teamwork system that improves communication among health care professionals. It includes a comprehensive set of ready-to-use materials and a training curriculum to successfully integrate teamwork principles into any health care system. These can be downloaded free at http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/

TeamSTEPPS is composed of the following four skills:

* Leadership is the ability to direct activities of team members; assess team performance; assign tasks; develop shared mental models; motivate team members; plan and organize; and establish a positive team atmosphere.

* Mutual support is the ability to anticipate other team members’ needs, and to shift workload among members to achieve balance.

* Situation monitoring is the capacity to develop a common understanding of the team environment, and to monitor teammate performance accurately.

* Communication includes the efficient exchange of information with other team members Historically, health care has regarded technical skills and competence as key to patient safety, and these are indisputably important , because healthcare professionals need to know what they are doing to maintain high standards of care. However, even the most technically qualified experts can encounter difficulties when under stress, which is why non-technical skills (both cognitive and social) need to be valued equally. Speaking up in the face of a potential breach of patient safety is everyone’s business - it is not about who is right, but what is right. In the aviation industry, professionals are taught how to speak up, how to listen and how to respond to any concerns expressed by team members. Similarly, we need to encourage and reward medical staff members who have the courage to speak up, independent of their rank or role, to ensure that their priority is ensuring safety.