2018 HPRCT Conference

Effective sensemaking in ambiguous situations and accurate and timely feedback are essential processes of High Reliability Organizing.
The problem of people not “speaking up” during sensemaking processes and providing feedback necessary for updating persists across all industries, especially healthcare, despite interventions to promote the behavior.
“The Joint Commission predicted that 80 % of the serious safety events occur due to miscommunications among healthcare professionals. Speaking up is one of the critical behaviors of patient safety that displays an important role for improving quality and patient safety in healthcare (Ahmet Nacioglu, 2016).”
“Ineffective communication is one of the most frequently identified root causes of sentinel events and contributes to the 400,000 deaths that occur each year due to preventable medical errors (Palatnik, 2016). Ineffective communication includes failure of staff to speak up when they know something is wrong that could potentially cause harm to the patient (Palatnik, 2016).”
Despite the many initiatives implemented in the last decade encouraging staff members to speak up for patient safety, many staff are still reluctant to to speak up. There are many influencing factors cited for staff unwillingness to speak up including fear of retaliation and fear of appearing incompetent.
However, we posit that the problem is perpetuated by the current model in which the solution to the problem is to “speak up.”
Therefore we propose the new model “speak in.” This model reframes ideas related to social structures, responsibility, purpose, and meaning of speaking and shifts influencing factors in a way that will drive increased communication and improve outcomes.