When Silence Kills

Often, healthcare givers know of an impaired or incompetent colleague, see coworkers taking shortcuts, or suspect a defect in a care process, but choose to remain silent and do nothing. This silence and inaction compromises the safety of patient care.

Magnitude of the Problem

In a recent survey of physicians, conducted by researchers from Massachusetts General Hospital, more than one-third of respondents didn’t agree that physicians should always report colleagues who are incompetent or impaired by conditions such as substance abuse or mental health disorders. Many also felt they were not prepared to effectively deal with, or report, impaired or incompetent colleagues.1

The 2002 Ethics Survey by Medical Economics2 yielded similar results with only 65% of the physicians who responded to the survey saying that they would report an impaired colleague.

The unwillingness to speak up certainly goes beyond doctors: a significant proportion of nurses, allied health professionals, hospital managers, etc. have sealed their lips when they knew they should have reported a problem. I haven’t got the figures to back this claim but I say this from more than 20 years of experience working in/with hospitals and knowledge that doctors, as a whole, are more outspoken than individuals in other professions.

Does It Matter?

Inadequate communication is consistently found to be the Number One root cause of sentinel events.3 See the graph below, which shows the root causes of 3548 sentinel events analyzed by The Joint Commission over a 10-year period.

Root causes identified from root cause analyses of 3548 sentinel events
Source: Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007

Failures in communication occur in various ways; not reporting an incompetent or impaired clinician or a suspected defect in the system are merely examples of poor communication (or to be more precise, no communication). Reporting a problem means that those who are in a position to do something about it will have an opportunity do so. It doesn’t guarantee that something will get done, but it certainly helps. On the other hand, if no one says anything, the onus of discovery falls on only a handful of individuals within the organization. Clearly, this is not a good situation when patients’ lives are at stake.

Why Don’t People Speak Up?

Commonly cited reasons why people choose to remain silent include:

  • Belief that someone else would deal with the problem.1
  • Belief that nothing would be done after the report was made.1
  • Safeguarding a job.
  • Avoidance of confrontation or reprisals.
  • Reluctance to put someone else’ career at risk.
  • Avoidance of legal risk, i.e. getting sued for slander.

These are just some reasons – I’m sure there are other reasons why dedicated, well-intentioned people don’t speak up. The hierarchical nature of our healthcare systems doesn’t help – many junior doctors and nurses are taught not to question authority, not to challenge. The macro-environment also plays a role; in Western countries, doctors are generally respected as members of the community, but in many parts of Asia, doctors are gods. In the latter case, no mortal human being (or fellow-god, for that matter) would question the decisions, actions, or behavior of a doctor for fear of eternal damnation.

What Can Be Done

Here are three suggestions of what can be done:

1. Improve Organizational Culture

Leaders are responsible for developing and nurturing an organizational culture which promotes transparency and openness. They need to be supportive of those who do voice concerns that are valid. This is of course easier said than done. Often, the tendency is to gag or otherwise get rid of the trouble-making whistleblower. Case in point (albeit an extreme example): Anne Mitchell, a Texas nurse who was charged and subsequently acquitted of a felony after alerting the state medical board that a doctor at her hospital was practicing unsafe medicine.

2. Provide the Right Training

Utilize resources that help individuals and teams develop the skills necessary to communicate difficult issues, e.g. Crucial Conversations®.

3. Take Appropriate Action

Leaders need to be alert to reports of clinician incompetence or impairment and to opportunities for process improvement. They should respond to them appropriately and in a timely manner and be seen as doing so. This will not only improve patient outcomes but also do wonders for staff morale, while encouraging more people to speak up.


If we continue to look the other way, more patients’ lives will be placed in harm’s way. As healthcare professionals, we have an ethical obligation to speak up when patient safety and quality care are put at risk.


  1. DesRoches CM, Rao SR, Fromson JA, Birnbaum RJ, Iezzoni L, Vogeli C, Campbell EG. Physicians’ perceptions, preparedness for reporting, and experiences related to impaired and incompetent colleagues. JAMA [Internet] 2010;304(2):187–93. Available from: http://dx.doi.org/10.1001/jama.2010.921

  2. Terry K. Impaired physicians. Speak no evil? Med Econ [Internet] 2002;79(19):110–2, 114, 117. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12407813

  3. The Joint Commission. (n.d.). Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2007 [PDF – 4.01 MB].