Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians.

A substantial barrier to progress in patient safety is a dysfunctional culture rooted in widespread disrespect. The authors identify a broad range of disrespectful conduct, suggesting six categories for classifying disrespectful behavior in the health care setting: disruptive behavior; humiliating, demeaning treatment of nurses, residents, and students; passive-aggressive behavior; passive disrespect; dismissive treatment of patients; and systemic disrespect.At one end of the spectrum, a single disruptive physician can poison the atmosphere of an entire unit. More common are everyday humiliations of nurses and physicians in training, as well as passive resistance to collaboration and change. Even more common are lesser degrees of disrespectful conduct toward patients that are taken for granted and not recognized by health workers as disrespectful.Disrespect is a threat to patient safety because it inhibits collegiality and cooperation essential to teamwork, cuts off communication, undermines morale, and inhibits compliance with and implementation of new practices. Nurses and students are particularly at risk, but disrespectful treatment is also devastating for patients. Disrespect underlies the tensions and dissatisfactions that diminish joy and fulfillment in work for all health care workers and contributes to turnover of highly qualified staff. Disrespectful behavior is rooted, in part, in characteristics of the individual, such as insecurity or aggressiveness, but it is also learned, tolerated, and reinforced in the hierarchical hospital culture. A major contributor to disrespectful behavior is the stressful health care environment, particularly the presence of "production pressure," such as the requirement to see a high volume of patients.

Perspective: a culture of respect, part 2: creating a culture of respect.

Creating a culture of respect is the essential first step in a health care organization's journey to becoming a safe, high-reliability organization that provides a supportive and nurturing environment and a workplace that enables staff to engage wholeheartedly in their work. A culture of respect requires that the institution develop effective methods for responding to episodes of disrespectful behavior while also initiating the cultural changes needed to prevent such episodes from occurring. Both responding to and preventing disrespect are major challenges for the organization's leader, who must create the preconditions for change, lead in establishing and enforcing policies, enable frontline worker engagement, and facilitate the creation of a safe learning environment.When disrespectful behavior occurs, it must be addressed consistently and transparently. Central to an effective response is a code of conduct that establishes unequivocally the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity. The code must be enforced fairly through a clear and explicit process and applied consistently regardless of rank or station.Creating a culture of respect requires action on many fronts: modeling respectful conduct; educating students, physicians, and nonphysicians on appropriate behavior; conducting performance evaluations to identify those in need of help; providing counseling and training when needed; and supporting frontline changes that increase the sense of fairness, transparency, collaboration, and individual responsibility.

Ethics: the joy of practice.

Dr John J. Conley was an integral part of the house of surgery in the latter part of the 20th century. Conley placed the ethical values of practice at the forefront of his teachings and transcribed many valuable lessons in his writings. In 1993, he wrote his version of the Hippocratic Oath outlining 12 important principles. Those principles are revisited here as a way to celebrate the joy of the calling that is medical practice. In addition, 7 new elements are added as a way to enhance that joy in the light of 21st-century medicine. The uplifting experience found in a career filled with ethical conduct is the legacy we should all strive to achieve.

Role models in surgery.

Our present training models date back almost 100 years. It is very apparent that trying to reshape an ageing system to meet the demands of today's patients and their physicians is just not going to be effective or efficient. In the past educators cared little about the working conditions for trainees such as the living and learning environment, social support and compensation models. You were just fortunate to be "chosen". Surgical educators in the 21st Century must reexamine their roles and consider what message they are sending to future generations on these and other critical issues that impact on safe patient care.

A trigger tool fails to identify serious errors and adverse events in pediatric otolaryngology.

OBJECTIVE: To identify and quantify errors and adverse events on an inpatient academic tertiary-care pediatric otolaryngology service, a trigger tool was developed and validated as part of a quality improvement initiative. STUDY DESIGN: Retrospective record review. SETTING: Children's Hospital Boston quality improvement initiative. SUBJECTS AND METHODS: Fifty inpatient admissions were reviewed. The gold standard for errors and adverse events identification was a detailed chart review by two board-certified otolaryngologists blinded to trigger tool findings. RESULTS: Trigger tool interrater reliability ranged from poor to high for admission triggers (kappa = 0.35, 95% confidence interval [95% CI] -0.07 to 0.76), discharge triggers (kappa = 0.63, 95% CI 0.27-0.99), medical records triggers (kappa = 0.61, 95% CI 0.11-1.00), and medication triggers (kappa = 0.90, 95% CI 0.71-1.00). Errors and adverse events were found in all admissions: three percent were potentially harmful, and 93 percent were documentation-related. CONCLUSION: The trigger tool was successful in identifying clerical and administrative errors and adverse events but failed to identify complex errors and adverse events. A hybrid approach for chart review may be cost-effective in pediatric otolaryngology.

Safety on an inpatient pediatric otolaryngology service: many small errors, few adverse events.

OBJECTIVES: Studies of medical error demonstrate that errors and adverse events (AEs) are common in hospitals. There are little data of errors on pediatric surgical services. METHODS: We retrospectively reviewed 50 randomly selected inpatient admissions to the otolaryngology service at a tertiary care children's hospital. We used a "zero-defect" paradigm, recording any error or adverse event-from minor errors such as illegible notes to more significant errors such as mismanagement resulting in a bleeding emergency. RESULTS: A total of 553 errors/AEs were identified in 50 admissions. Most (449) were charting or record-keeping deficiencies. Minor AEs (n = 26) and moderate AEs (n = 8) were present in 38% of admissions; there were no major AEs or permanent morbidity. Medication-related errors occurred in 22% of admissions, but only two resulted in minor AEs. There was a positive correlation between minor errors and AEs; however, this was not statistically significant. CONCLUSIONS: Multiple errors occurred in every inpatient pediatric otolaryngology admission; however, only 26 minor and eight moderate AEs were identified. The rate of errors per 1,000 hospital days (6,356 per 1,000 days) is higher than previously reported in voluntary reporting studies, possibly due to our methodology of physician review with a "zero-defect" standard. Trends in the data suggest that the presence of small errors may be associated with the risk of adverse events. Although labor-intensive, physician chart review is a valuable tool for identifying areas for improvement. Although small errors were common, there were few harms and no major morbidity.