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PSNet: Patient Safety Network
Journal Article

Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals.

Webb LE, Dmochowski RR, Moore IN, et al. Joint Commission journal on quality and patient safety. 2016;42:149-64.

Disrespectful behavior and lack of speaking up are hallmarks of dysfunctional safety culture, which can be resistant to change. In this pre-post study, investigators implemented a voluntary reporting system to allow health care team members to report "disrespectful or unsafe conduct." Designated trained peers had cup-of-coffee conversations to discuss reports with the associated individuals, and after receiving this feedback most providers did not have a repeat report completed about them. Even when there were two or more complaints about a provider, the vast majority of individuals were able to regulate their behavior following receipt of feedback. The number of reports increased during the intervention, suggesting that team members saw a benefit to reporting disrespectful or unsafe behaviors. This comprehensive, system-wide intervention demonstrates that safety culture can improve over time.