Silence kills if no one is willing to speak up

'Make candor a core competence'

Checklists and clear protocols for clinical care have been highly successful in infection prevention and other fields, but can be easily undercut by a simple non-action: silence.

Following up on earlier work on this topic, the Association for Operating Room Nurses (AORN) and several partners reported in The Silent Treatment that health care has yet to fully overcome a culture wherein people observe errors but fear the consequences of speaking up.1

The study included data from more than 6,500 nurses and nurse managers from health systems around the United States during 2010. All research participants were members of the AORN and the American Association of Critical-Care Nurses. The study used two research instruments: a "story collector" and a traditional survey. The story collector generated qualitative data, while the survey recorded purely quantitative data.

The researchers found that 85% of respondents have been in a situation where a safety tool warned them of a problem. In addition, 32% said this happened at least a few times a month, a finding that confirmed that safety tools work and that checklists, protocols, and warning systems have an essential role in patient safety.

However, the research also documented that the effectiveness of safety tools is undermined by so-called "undiscussables." Of the nurses who had been in situations where safety tools worked, 58% had also been in situations "where they felt unsafe to speak up about the problems or where they were unable to get others to listen," the researchers noted.

The research findings pointed to several key hazards, including:

Dangerous shortcuts: Overall, 84% of respondents said that 10% or more of their colleagues take dangerous shortcuts. Of those respondents, 26% said these shortcuts have actually harmed patients. Despite these risks, only 17% have shared their concerns with the colleague in question.

Incompetence: Overall, 82% say that 10% or more of their colleagues are missing basic skills and, as a result, 19% say they have seen harm come to patients. However, only 11% have spoken to the incompetent colleague.

Disrespect: Overall, 85% of respondents say that 10% or more of the people they work with are disrespectful and therefore undermine their ability to share concerns or speak up about problems. And yet, only 16% have confronted their disrespectful colleague.

"Fortunately, not all survey respondents remained silent," the authors state. "The study identified a small minority of nurses who spoke up when they observed dangerous shortcuts, incompetence, or disrespect. By studying these successful outliers, the research uncovered the high-leverage behaviors all healthcare practitioners should master in order to change the trajectory of harmful patient care."

The report underscores that while safety tools are one part of the solution to improving patient care, they do not compensate for crucial conversation failures in the hospital. "Silence still kills," the authors conclude. "It's time for healthcare systems to make candor a core competence."

Editor's note: The full AORN report is available at


1. Maxfield D, Grenny J, Lavandero R, et al. The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives. Executive Summary. 2010 Available at: