Assertion: Making Sure Your Concern is Heard to Avoid Errors
Part 2 of the Working as a Health Care Team series

The following scenario is drawn from an incident reported to CHPSO:

During patient rounds a pharmacist asked if the patient should be on GI prophylaxis because he had an NG tube and recent abdominal surgery.The physician’s response was to draw up his fingers like a gun and “shoot” the pharmacist for asking the question.The pharmacist was embarrassed and intimidated by the physician’s actions and kept quiet for the remainder of rounds.He also commented to a co-worker that this was the last time he was going to speak up during rounds when Dr.X was around.

Inhibition of communication between health care professionals is clearly linked with reported errors. This type of response would make most people feel intimidated and avoid future confrontations that may result in a similar situation. The authority gradients that are prevalent in health care are a leading cause of inhibited communication. [1] This problem can occur not only between health care providers, but between patients and their health care providers. This is the premise behind the “Speak Up” campaign that was launched by The Joint Commission and CMS, which urges patients to take an active role in preventing health care errors by becoming involved and informed participants on their health care team.[2]

The solution to reduce these errors is to change the culture of the hospital to one of collaboration through advocacy and assertion. Advocacy and assertion are actions that advocate for the patient regardless of the situation. It is generally caused when team members’ viewpoints don’t coincide with that of a decision maker. When a team member disagrees with a decision, or has knowledge that could potentially change the situation, the member must assert a corrective action in a firm and respectful manner.

This is done with the use of an assertive statement: a non-threatening statement that ensures that critical information is addressed.

The AHRQ provides the following framework for an assertive statement:[3]


*Note that this format is similar to SBAR: situation, background, assessment, recommendation

Two Challenge Rule

What do you do if your concern is ignored or dismissed? It is your responsibility to assertively voice your concern at least two times to ensure that it has been heard. The member being challenged must acknowledge the concern. If the outcome is still not acceptable, take a stronger course of action, utilizing a supervisor or chain of command.

If the issue is critical, empower any member of the team to “stop the line” if he or she senses potential harm to a patient. This is an action not to be taken lightly, because it requires immediate cessation of the process and resolution of the safety issue. However, staff need to know that they are supported by their management and administration should they decide that this is a necessary step in advocating for the patient.

It is important to do all this with respect – the goal is to ensure that all members of the healthcare team are aware of the same issues and concerns without finger pointing or blame.

Cultivate your Culture for Advocacy and Assertion

The assertive statement and the Two Challenge Rule will be more effective if the organization prepares its physicians, nurse leaders, and other professionals to receive them.  One surgeon at a recent patient safety seminar make a remark about his reaction to receiving such a statement. A nurse responded with a compelling “I’m acting as the patient’s advocate!”; “What do you think I am?” he blustered in reply.

We must help our medical staff and other clinical leaders to understand the value of strengthening the practice of sharing patient care information and viewpoints: the opportunity to prevent medical errors. We must prepare them to recognize and patiently receive that assertive statement so that an air of altercation does not immediately come into play.

Start with one unit, help physicians and nurses talk about strengthening advocacy and assertion, and have them “role play’ a few scenarios. Encourage physicians who discover the practice to be beneficial – perhaps even preventing an error for one of their patients- to tell their peers about the value of advocacy and assertion in a culture for patient safety.


1. Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety Training Materials. Available at: Accessed September 17, 2013
2. The Joint Commission. Facts about Speak Up Initiatives. Available at: Accessed September 17, 2013.
3. Agency for Healthcare Reasearch and Quality (AHRQ). Appropriate Assertion Call (Transcript). December 14, 2010. Available at: Accessed September 17, 2013.