Example of a communication guide included in an OR crisis manual.

Example of a communication guide included in an OR crisis manual.

Before takeoff, the captain (CAM-1) and the first officer (CAM-2) of Air Florida Flight 90 were discussing the power output of the engines. The conversation below took place immediately prior to the aircraft crashing (asamonitor.pub/3i8uKy8):

15:59:51 CAM-1: It's spooled. Real cold, real cold.

15:59:58 CAM-2: God, look at that thing. That don't seem right, does it? Uh, that's not right.

16:00:09 CAM-1: Yes, it is, there's 80.

16:00:10 CAM-2: Naw, I don't think that's right. Ah, maybe it is.

16:00:21 CAM-1: Hundred and twenty.

16:00:23 CAM-2: I don't know.

Even without extensive aviation knowledge, you can see in the transcript above (emphasis added) that the first officer raises concerns several times, but the message wasn't received. The speech that he used was mitigated (Linguistic methodology for the analysis of aviation accidents.1984). Mitigation softens language and, rather than stating something explicitly, often poses it as a question, suggestion, or hint (asamonitor.pub/3wd0kOR). The more mitigated an utterance, the less likely that the message will have the intended effect (Linguistic methodology for the analysis of aviation accidents.1984). Consider the following examples that might be heard in the OR during a time of rapid blood loss:

The statements run down the table from least to most mitigated. While the aggressive statement certainly gets the point across, incivility has significant and negative consequences on team performance (BMJ Qual Saf 2019;28:750-7). When the intent is to obtain the rapid infuser, the command is the most direct, while the suggestion, question, preference, and hint are all indirect. In times of urgency, health care professionals should voice a concern at least twice to ensure that it has been heard (asamonitor.pub/3AhUnDC). Although it feels more natural to raise a concern with indirect language, an increasing level of (respectful) assertiveness may be necessary. One tool for using graded assertiveness is to use CUS words (asamonitor.pub/3AhUnDC). Applying the acronym, first you would state your Concern. If the message is not received, you would then explain why you are Uncomfortable with the situation. Finally, you would announce there is a Safety issue present. Other acronyms for graded assertiveness exist, such as PACE (Probe, Alert, Challenge, Emergency). More important than which method is chosen is that it is used universally at your institution. Practice and support from senior leadership within the institution are essential to achieving comfort in speaking up and using these techniques (ASA Monitor 2021;85:19-21). Once the entire team gets accustomed to what the signal words are, they will understand that their use indicates a serious safety concern is being raised that must be addressed.

This safety tip focuses on the common practice of mitigating speech. While perhaps it's more socially acceptable to use indirect language, if you feel that your concern isn't being acknowledged appropriately, it is your responsibility to increase the amount of assertiveness and ensure you are heard. Being as direct as possible, while remaining respectful, is the key to successfully communicating a threat to patient safety.