Hospital case managers are in a prime position to see many things that consistently go wrong or need improvement but, like everyone else, may be reluctant to bring them up, says John D. Banja, PhD, professor, department of rehabilitation at Emory University in Atlanta, and a medical ethicist at Emory’s Center for Ethics.

Based on his experience, Banja has come up with four reasons why health professionals don’t speak up even when they know the system is not working properly.

• They fear retaliation.

• They don’t know how.

• They believe the leadership will not be responsive.

• They believe it’s not their job.

But, as advocates for their patients, hospital case managers have an obligation to speak up whenever they see a safety breach, adds Patrice Sminkey, RN, chief executive officer for the Commission for Case Management Certification.

“If you don’t speak up, the person who made an error may do it again. When case managers see a breach, they should make it a teachable moment and take the opportunity to educate the person making the mistake,” she says.

For instance, if a staff members fails to wash his or her hands before seeing a patient, say something like, “This is a gentle reminder that hand washing is a must. Most infections are spread through poor hand washing,” Sminkey suggests.

How involved case managers can be in patient safety depends on how the organization views the case management role, says Patrice Spath, RHIT, principal in Brown-Spath & Associates, a Forest Glen, OR, healthcare quality consulting firm. “If case managers are just viewed as someone who arranges post-discharge services and calls the health plan, they are less apt to be engaged in safeguarding the patient. Ideally, the organization sees case managers as another member of the clinical team and they are listened to when they question what is going on with a patient,” she says.

Poor hand hygiene may well be the No. 1 patient safety breach in the healthcare arena, Banja says. Failure to check patient arm bands, not gowning up appropriately, not performing safety checks, violating policies on storing and dispensing medications (like failing to review the Five Rs — Right patient; Right drug; Right dose; Right time; Right route — when giving medication) are also significant problems, Banja adds.

Hospital staff should be encouraged to speak up when they see a safety breach, he says. “It’s always better to nip the problem in the bud. The longer we let people go when they are doing the wrong thing, the more entrenched the deviation will become,” Banja says.

Healthcare professionals who are “in the trenches” often deviate from rules and regulations they find counterintuitive and that interfere with their productivity targets, Banja says. “One of the hard things about healthcare is that it is almost impossible to comply with all the procedures and policies,” he says.

“The fact is we largely can’t prevent errors unless we replace humans with machines. But we can prevent many disasters if health professionals would be more aggressive and courageous in attending to system weaknesses, including compliance with rules and standards,” he adds.

One of the greatest challenges healthcare leaders face is to cultivate a non-punitive and blameless environment so that the staff know how to respond to a physician or a nurse who is not working according to expectations or professional standards, Banja says.

“Leadership has to cultivate an environment where people feel safe speaking up about issues that threaten patient safety without fear of retaliation,” he says.

Most hospitals have a formal system of reporting incidents, Banja says. “But hospitals are a very social environment. People work closely together and it often feels like a family. You can have all the formal incident reporting systems in place but if someone feels the person who made the error will retaliate, many people won’t report it,” he says.

“The challenge is to create an atmosphere of safety and respect whereby all healthcare personnel can speak up in a constructive and patient-centered way,” Banja says.