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Organizational silence threatens patient safety

Organizational silence refers to the tendency for people to do or say very little when confronted with significant problems or issues in their organization or industry. In a recent article, Kerm Henriksen, Ph.D., and Elizabeth Dayton, M.S., of the Agency for Healthcare Research and Quality (AHRQ), describe the individual, social, and organizational factors that contribute to organizational silence and can threaten patient safety. They cite several individual factors that contribute to clinician silence. For example, the availability heuristic suggests that if relatively infrequent events that harm patients go unreported and are not openly discussed, clinicians don't believe these events are a problem at their hospital. A second factor is self-serving bias. People tend to view themselves as "above average" in their chosen field of work and so "why do things differently?" Successes are attributable to their own abilities but failures are blamed on situational factors. Finally, members of all organizations display a strong tendency to perpetuate the status quo and not speak up or rock the boat.

Several social factors also underlie clinician silence. There is great pressure to conform in order to gain acceptance and work harmoniously with coworkers. Diffusion of responsibility is also a problem. In clinical settings, individual roles and responsibilities are often assumed rather than clearly spelled out. Under these conditions of diffused responsibility, components of care that should be attended to are often missed. Also, managers who seek blame and attribute error to the individual failings of careless or incompetent staff create a microclimate of distrust.

Finally, three areas of organizational vulnerability that warrant closer attention are unchallenged beliefs, the perceived qualities of the good worker who "works around" problems rather than focusing on the contributory factors to the problem, and lack of understanding of the interdependence of complex clinical systems. The authors recommend that health care leaders and managers value dissent and multiple perspectives as signs of organizational health, and question agreement, consensus, and unity when they are too readily achieved.

See "Organizational silence and hidden threats to patient safety," by Dr. Henriksen and Ms. Dayton, in the August 2006 HSR: Health Services Research 41(4), pp. 1539-1554. Reprints (AHRQ Publication No. 06-R060) are available from the AHRQ Publications Clearinghouse.

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