Silence Kills 2.0: How Communication Failures Stifle Innovation and Harm Patients

In health care organizations in which silence is the norm, questionable competence, rule-breaking, and mistakes ("crucial moments") often persist, putting patients and clinicians at risk. Silence may also impede an organization's behavioral agility-the speed at which care teams adopt new technologies and evidence-based practices.

Twenty years after the Silence Kills study, this study addressed these questions: Does silence still happen? Does silence kill innovation?

In a quantitative cross-sectional descriptive study, clinicians across the United States, including nurses, other care providers, and leaders, completed an online instrument incorporating the 2005 Silence Kills survey and other measures to understand how often clinicians perform 4 behaviors related to crucial moments (speaking up, reminding, holding each other accountable, and challenging assumptions) that were hypothesized to increase behavioral agility. Demographic data also were collected.

Of 5163 respondents, 3500 provided analyzable data. Fewer than 10% of respondents spoke up during crucial moments in 2005; in 2025, it was 32%, suggesting significant progress in overcoming the culture of silence. A continued strong relationship between speaking up and health care outcomes was found. A culture of candid communication also strongly correlated with behavioral agility (r = 0.71), patient safety, patient experience, and employee engagement and retention (P < .001).

Improvements in patient care, employee satisfaction, and adoption of evidence-based practices are possible when clinicians are empowered to speak up in crucial moments. Artificial intelligence use is expected to accelerate progress toward improved patient outcomes, reduced costs, and increased access to care, but only if the human systems required for implementation increase their capacity to absorb new ideas.