• Stephen Harden

The Two Biggest Barriers to Patient Safety Today

Find out what the experts know and learn three steps you can take to fix one of them.



The two biggest barriers to hospitals ensuring patient safety are:

  • Nurses’ fear of retribution if they speak up and;

  • Poor communication during handoffs.

Who says?


Hospital C-suite executives and risk managers surveyed this year by American International Group Inc. (AIG) identified the top two issues: nurses fearing retribution for raising patient safety issues, and patients being handed off multiple times to different hospital staffers and departments, which don’t always coordinate or communicate well.


Regarding the fear of speaking up for safety, the AIG survey agrees with the research of the National Association for Healthcare Quality (NAHQ). The NAHQ finds that despite 20 years of quality and safety improvements, healthcare providers still hold back from speaking up, fearing retaliation and intimidation.


Physicians agree, even though they are often the reason nurses are fearful of speaking up. Peter Angood, M.D., CEO of the American College of Physician Executives says the fear of retaliation is so “very distinct and quite palpable” that some hospital staff are afraid to mention a threat to patient safety exists.


As a result of my own work with 140 healthcare organizations over the last 13 years, I have come to the conclusion that if we could get staff to speak up without fail when they perceive a problem with patient care, we could fix 85% of patient harm.


Following are the three steps to changing the fear of speaking up:


1. Train your staff to speak up.

Telling is not training! “Training” means you have told them how, shown them how (with a demonstration), given them an opportunity to practice through role play and/or simulation, and given them expert feedback on their practice.


If you haven’t done this you haven’t “trained.”


Here is a link to a free training resource on speaking up you can use during educational sessions or staff meetings. To make the time commitment for this training more manageable you could cover one of the case studies in less than five minutes during a shift briefing or morning report.


2. Put an Escalation Policy in place.

Staff must absolutely know whom to call to escalate an issue to get a satisfactory resolution. The number one reason trained nurses don’t speak up is that there is no mechanism in place to give them immediate support at the bedside. If you are not willing to do this, don’t bother to do assertion training.


3. Put a “No Retribution Policy” in place.

The second most oft cited reason for not speaking up is captured in this comment I recently received from a nurse. “Sure, administration will support me when I speak up. They’ll even come to the bedside if I need them to. But later, for the next three months, that physician will make my life a living hell. And no one will do anything about it.”


These three items go hand-in-hand. Train. Escalate. Stop retribution. Three legs of a three-legged stool. Without all of them you will not overcome one of the two biggest barriers to patient safety today.




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