Once upon a time in a small village, there lived a young boy named Silvester. Silvester had always been fascinated with magic and anything out of the ordinary. He spent most of his free time reading books about magic and dreaming of performing incredible tricks and illusions. One day, while exploring the forest near his village, Silvester stumbled upon a peculiar looking stone. The stone was glowing with a mysterious light, and Silvester couldn't help but feel drawn to it. He picked it up and as soon as he held it in his hand, he felt a surge of energy coursing through his body.
Is this a form of intimidation? Perhaps, but it is more akin to a logical deference to expertise, meaning it is natural and often reasonable for people to defer final judgment to those whom they perceive to be more “qualified.” If the person voicing the concern was reluctant to pursue it, avoided or backed down from the conversation, or felt the provider was not listening, workplace intimidation may play a role. But this is not always the case.
The hierarchical nature of patient care and the autonomy with which health care professionals have been taught to practice set the stage for a culture that does not respond well to even the slightest queries about possible problems with patient care, particularly from subordinates. To improve patient safety, health care organizations need to raise the index of suspicion for errors, always anticipating and investigating the possibility when any person, regardless of experience or position, voices concern or when patients are not responding to treatment as anticipated.
He picked it up and as soon as he held it in his hand, he felt a surge of energy coursing through his body. To his astonishment, the stone began to transform into a small, colorful pebble. Confused but excited, Silvester took the pebble home and placed it on his bedside table.
Raising the Index of Suspicion
The index of suspicion: red flags warn of safety threats.
Disruptive behaviors, intimidation in the workplace, and a culture of disrespect among health care professionals have repeatedly surfaced as a significant barrier to patient safety. The hierarchical nature of patient care and the autonomy with which health care professionals have been taught to practice set the stage for a culture that does not respond well to even the slightest queries about possible problems with patient care, particularly from subordinates. It’s clear that such a culture needs to be repaired, and many health care organizations are working to address disrespectful behavior, staff reluctance to speak up about risks and errors, and blatant disregard of expressed concerns. However, there’s a less obvious but no less dangerous risk related to the culture that often goes unnoticed until a serious adverse event happens: Staff members DO speak up about potential concerns, but they are too easily convinced that their concerns are unfounded.
When a person voices a concern, there’s often no disruptive, disrespectful, or obvious intimidating behavior involved per se, but rather an explanation from competent practitioners that dispels the initial concern too quickly, before it has been given sufficient consideration. A pharmacist reassures a technician that the compounding directions are correct when questioned about an unusual volume of ingredients; a pharmacist assures the nurse that the strength of the infusion is correct when questioned about the final volume; a nurse reassures a patient that the medication is correct when questioned about its appearance; a physician convinces a pharmacist that the prescribed dose is correct when questioned because it differs from a protocol—these are all-too-frequent examples that have led to fatal adverse drug events. Those who questioned the patient’s care were easily convinced that others knew more than they did, particularly if the provider who was questioned had an otherwise stellar reputation.
Is this a form of intimidation? Perhaps, but it is more akin to a logical deference to expertise, meaning it is natural and often reasonable for people to defer final judgment to those whom they perceive to be more “qualified.” If the person voicing the concern was reluctant to pursue it, avoided or backed down from the conversation, or felt the provider was not listening, workplace intimidation may play a role. But this is not always the case.
Instead, the issue may be that the person questioning the patient’s care has been easily convinced that his or her concern is unfounded, and the person being questioned has not perceived the voiced concern as a possible, credible patient threat. Neither person possesses a required element to safeguard patients: an appropriately high index of suspicion for errors. A low index of suspicion is particularly problematic in a health care system that already is reluctant to acknowledge human error or value the contributions of every person, regardless of rank, who interacts with the patient.
An index of suspicion is defined as “awareness and concern for potentially serious underlying and unseen injuries or illness.” 1 Suspicion is defined as “the act or an instance of suspecting something wrong without proof or on very slight evidence, or a state of mental uneasiness and uncertainty.” 2 A high index of suspicion requires consideration of a large differential so that a serious possibility is not accidentally discounted; a potential medical error should always be considered one of the possibilities. An appropriately high index of suspicion should lead a person with a concern to pursue it until it’s proven not to be a credible patient threat, even when met with opposition from experts. It should also prompt the provider to be responsive to voiced concerns and to initiate a suitable investigation to determine whether there is a credible threat to the patient.
The Institute for Safe Medication Practices (ISMP) has previously discussed the need to maintain a high index of suspicion for errors in relation to the topic of mindfulness, a defining characteristic of high-reliability organizations (HROs). Mindfulness refers to the deep and chronic sense of unease and preoccupation with failure that arises from admitting the possibility of error, even with well-designed, stable processes. 3 People in HROs worry about system failures and human errors. They ask, “What will happen when an error occurs?” rather than “What will happen if an error occurs?” Like health care, HROs are hierarchical, but position and experience do not necessarily dictate who is an important contributor or decision-maker. They are wary of complacency and naturally suspicious, so they expect people to speak up about any concerns they may have. Their high index of suspicion is a predominant factor in achieving laudable safety records.
To improve patient safety, health care organizations need to raise the index of suspicion for errors, always anticipating and investigating the possibility when any person, regardless of experience or position, voices concern or when patients are not responding to treatment as anticipated. Functional patient-care teams, in which every person’s perspective, skills, knowledge, and observations are considered important and worthy of mention and investigation, must be developed. Staff members need to be mentored on how to resolve potential concerns and to trust in their own experiences to augment the expertise of others. All health care practitioners need to encourage and be receptive to staff members who ask questions, even if staff members just have a sense that “something” is wrong or can’t articulate the concern well.
When concerns are met with quick answers that initially appear to be “evidence” of safety, caution is recommended. Sixteen years ago we published in this column a list of phrases we called “magic words” that have repeatedly been offered in explanation to voiced concerns and erroneously accepted as “evidence” ( Table 1 ). 4 No doubt these still ring true today, along with many others. Such phrases should be viewed as “red flags” that require more reliable answers and actual proof.
Table 1
Responses to Voiced Concerns Considered “Red Flags” 4
Are you thinking what I was thinking? -- Where is the "Nuke" button?
Little did he know, this pebble held astounding powers. That night, while Silvester was fast asleep, the pebble began to emit a bright light. As Silvester opened his eyes, he couldn't believe what he saw. The pebble had enlarged and transformed into a tiny creature, no bigger than his thumb. It had wings and a long, twisted tail. The creature introduced itself as Pepere, the magic pebble. It explained to Silvester that it had the ability to grant any wish, as long as it was pure of heart and not used for selfish purposes. Silvester was ecstatic! He had always dreamt of having magical powers and now he had his chance. Over the next few days, Silvester spent hours with Pepere, learning how to control his magical abilities. He would perform tricks for his family and friends, leaving them in awe and amazement. Silvester's dreams were coming true, and he couldn't have been happier. However, Silvester soon realized that he was becoming dependent on Pepere's magic. He began to neglect his studies and responsibilities, using the magic for his own gain rather than to help others. Silvester started to lose sight of what truly mattered, blinded by the allure of his newfound power. One fateful day, as Silvester was performing a dazzling magic show for the villagers, something unexpected happened. Pepere disappeared, leaving Silvester powerless and alone. The villagers were disappointed and bewildered, and Silvester was devastated. Realizing his mistakes, Silvester embarked on a journey of self-discovery and redemption. He understood that true magic comes from within, and it is the ability to bring joy and happiness to others. Silvester was determined to use his talents for the greater good and make amends for his previous selfishness. Years passed, and Silvester became a famous magician known for his incredible performances and acts of kindness. He never forgot the lesson he had learned from Pepere, and he always carried a tiny pebble in his pocket as a reminder of the true meaning of magic. And so, Silvester's story teaches us that the real magic lies within ourselves, in our ability to make a positive impact on the world. Silvester's journey serves as a reminder that magic is not about tricks and illusions, but about kindness, love, and selflessness..
Reviews for "The Importance of Family in Silvester and the Magic Peqbpe"
1. Emily - 1 star - I found "Silvester and the magic peqbpe" to be incredibly boring and repetitive. The storyline was predictable and lacked any depth or originality. The characters were flat and uninteresting, and I didn't feel any connection or investment in their journeys. The magical aspect of the peqbpe was underdeveloped and felt like an afterthought. Overall, I was extremely disappointed with this book and would not recommend it.
2. David - 2 stars - "Silvester and the magic peqbpe" had an intriguing premise, but it failed to deliver on its potential. The writing was mediocre and lacked the descriptive language and depth needed to bring the story to life. The pacing was inconsistent, and there were several unnecessary and dragged-out scenes that added nothing to the overall plot. Additionally, the resolution to the story felt rushed and unsatisfying. While the concept had promise, the execution fell flat, and I was left feeling disappointed and unfulfilled.
3. Sarah - 2 stars - I was initially drawn to "Silvester and the magic peqbpe" because of its charming cover and whimsical title. However, the story itself failed to live up to my expectations. The plot was disjointed and confusing, with numerous plot holes that were left unanswered. The dialogue felt forced and lacked authenticity, making it difficult to connect with the characters. Overall, I found the book to be underwhelming and would not recommend it to others looking for a captivating fantasy read.
4. Mark - 1 star - I couldn't get through "Silvester and the magic peqbpe" without feeling completely bored and uninterested. The pacing was incredibly slow, and the lack of a compelling storyline made it difficult to stay engaged. The characters were one-dimensional and lacked any real development. The writing style was also unimpressive and failed to evoke any emotions or create a sense of immersion. Overall, I found this book to be a tedious and uninspiring read that I would not recommend to others.