Most doctors and nurses keep quiet about medical errors.

More than half of 1,700 doctors, nurses, and other staff surveyed at 13 U.S. hospitals witnessed mistakes made by their colleagues, including serious incidents of incompetence, but less than 10 percent discussed the problems with those same coworkers, according to a study sponsored by consulting company VitalSmarts and the American Association of Critical-Care Nurses (AACN). The study concluded that this lack of communication contributes to avoidable errors as well as poor work environments.

Researchers identified seven areas where communication among hospital workers is critically important: broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. Even though most health care workers said they and their colleagues do not have these problems, 88 percent of doctors and 48 percent of nurses and other health care providers surveyed said they have worked with colleagues who showed poor judgment, and 68 percent of doctors and 34 percent of nurses and other staff reported being concerned about the competency of a doctor they have worked with. In addition, 84 percent of doctors and 62 percent of nurses and other health care workers saw coworkers taking "shortcuts that could be dangerous to patients."

But the study found that only 8 percent of doctors who were concerned about a nurse's incompetence spoke with that person to share their concerns, and only 12 percent of nurses did so. And less than 1 percent of nurses or doctors spoke up to a doctor whom they believed to be incompetent.

"The challenge here is that hospitals are just like any other organization," said Joseph Grenny, president of Vital-Smarts. "We've worked in dozens of different industry groups, and everywhere people are reluctant to call others on the carpet when they make mistakes or do something that could be hurtful. This happens in aerospace, heavy industry, high tech, as well as banking and other industries. The problem is that it has more severe consequences in hospitals."

Other studies have shown that medical errors in hospitals are common. A January report linked 20 patient deaths in Minnesota hospitals over a 15-month period to medical errors. In addition, a group of researchers at Harvard University reported in the January 13, 2005, and October 28, 2004, issues of the New England Journal of Medicine that not only are sleep-deprived doctors more likely to be in a car crash after working long shifts, but they also make one-third more medical errors during those shifts than while working normal hours.

"It was not surprising that nurses would be reluctant to confront physicians," noted Grenny about the VitalSmarts/AACN study. "Everybody knows there's a power gradient in health care. But the big surprise was that doctors are equally unlikely to confront nurses they believe are incompetent. Instead, they work around them. They're also unlikely to confront fellow doctors, even though there might be peer camaraderie."

The reasons for the silence varied, said Grenny. Many workers said they were too busy or disliked confrontation. More often, workers felt that pointing out errors was the job of a manager or peer review group. But the study found that managers are also reluctant to confront health care workers.

Communication, sound health care, and a positive work environment are inextricably linked, said AACN President Kathleen McCauley. She estimated that a large percentage of error-related injuries are a result of poor communication among health care workers.

"It used to be that a nurse would say, 'Wait a minute, I thought it was his left foot that was a problem, not his right. But I can't speak up, they'll start screaming at me,'" McCauley said.

Despite communication improvements since that time, McCauley said, problems still exist. "We've got to ensure we have a culture where everyone can speak up, such as in places where they take a time-out before making the incision, where everyone is involved, where they go over every single thing: 'Do we have the right patient?', 'Are we looking at the right leg?' Even the housekeeper can say in such places, 'Wait a minute, he was telling me out in the hallway that his left foot hurts. What are you doing working on his right foot?'"

The researchers found that those few workers who were "confident in their ability" to confront their coworkers on the study's areas of concern were more likely to be happy in their jobs and that they were likely to "observe better patient outcomes." To reinforce these conclusions, the AACN released, along with the study, standards for healthy work environments, including skilled communication and collaboration among health care workers.

The study, "Silence Kills: The Seven Crucial Conversations for Healthcare," is available at www.rxforbettercare.org/ SilenceKills.pdf.