Examining Barriers and Motivations to Speak up on Medical Errors in a Simulated Clinical Emergency: A Mixed-Methods...

Effective communication between team members is essential during the resuscitation of critically-ill patients. Failure of junior doctors to speak up and challenge erroneous clinical decisions made by their senior doctors is a serious communication failure which can result in catastrophic outcomes and jeopardize patient safety. Crisis resource management (CRM) and conflict resolution tools have been increasingly employed in the healthcare setting to reduce communication failure among healthcare providers and improve patient safety during crisis situations. The aims of our study were to: 1) evaluate the factors affecting junior doctors' ability to speak up on medical errors, 2) examine the effectiveness of CRM and conflict resolution tools, and 3) formulate a communication framework directed at training junior doctors in appropriate intellectual questioning of authority. From January to April 2019, we recruited twenty-five second-year postgraduate junior doctors working in an Emergency Department in Singapore. We provided training in CRM and conflict resolution communication for participants in the intervention arm. Participants underwent a high-fidelity simulated resuscitation scenario which was standardized to include faculty misdirection in the form of erroneous instructions given by a role-played senior doctor. We observed if participants appropriately challenged the erroneous instructions. We subsequently interviewed participants on their response during the simulation to elicit their barriers and motivations toward challenging authority. Video recordings were analyzed by an independent panel of investigators. Participants employed various non-verbal and verbal approaches when challenging erroneous decisions. We uncovered multiple personal, interpersonal, and situation-based factors influencing the junior doctor's willingness to challenge erroneous decisions made by seniors. From their responses, we conceptualized a theoretical model designed as a "weighing scale" to demonstrate how junior doctor's eventual response is the outcome of a delicate interplay of multiple barriers and motivations. Our intervention did not significantly increase the participants' likelihood of challenging authority (69% in control arm vs 75% in intervention arm, p = 1.00). Our study provides insights into the mindset of junior doctors when faced with the dilemma of challenging authority on medical errors. Established CRM training may not be effective in addressing the challenges junior doctors face when communicating against the hierarchal gradient. We propose strategies to further develop and optimize CRM training to enhance its value for junior doctors. Drawing from our findings, we formulated a "SAFE" communication tool (State the safety concern, suggest Alternative course of action, Support with Facts, Engage via Enquiry) directed at helping junior doctors in appropriate intellectual questioning of authority.