Avoid "Shooting from the Hip"

Have you ever answered a question even though you were unsure of the answer? Perhaps the fear of looking dumb was so overwhelming that you thought any answer was better than no answer? Under this pressure, we may “shoot from the hip,” forming an answer to a question in seconds and taking no time to research it or consider it in depth. If the answer is wrong—which it often is—we “misspeak.”

Recently, a patient encountered several instances of “misspeaking” by health care workers. The patient had just undergone dental work, including a root canal. Her dentist had prescribed amoxicillin to prevent an infection; the patient, however, had a documented allergy to penicillin, which was listed in her dental record. When the patient received the handwritten prescription, she asked the dentist’s receptionist if it was safe to take amoxicillin given her penicillin allergy. The receptionist assured the patient that the dentist had verified the prescription.

When the patient dropped off the prescription to be filled at the pharmacy, she asked the pharmacy technician to verify that the medication ordered was not penicillin since she was allergic to penicillin. The technician quickly replied, saying, “No, it’s not. That’s why your doctor prescribed it.” Trusting the health care workers, she took the medication. Several days later, she began to notice a rash that extended over her entire body, which was diagnosed as an allergic reaction to amoxicillin. She was fortunate that she did not experience an anaphylactic reaction.

Health care workers are often pressured to give an answer instantly. Pressure to meet time constraints may contribute to this. For pharmacists, meeting dispensing time expectations while juggling incoming prescriptions, insurance adjudication issues, and clinical clarifications with prescribers may contribute to this pressure. Thus, health care practitioners may shoot from the hip and misspeak when trying to satisfy a patient or quickly answer a patient’s question because they simply need to move forward with their work. To reduce these behaviors, consider the following:

• Supportive culture. Build a culture in which all staff, regardless of rank, experience, or training, feel safe and supported when acknowledging that they do not know the answer to a question. The responsibility for giving staff permission to say “I don’t know” belongs with management who should recognize that, in a learning organization, the first step to learning is knowing there are things you do not know and things you did not even know you did not know.¹

In highly reliable organizations with excellent safety records, there is a perpetual recognition of the “unknown unknowns” that leads to a deference to expertise.² In health care, we need to give staff permission to say, “I don’t know” and to seek out the correct answer from those with expertise. We must also allow the time necessary for seeking out the correct answers whenever possible.

• Group discussions and simulations. Provide training that helps staff assess whether they should answer a question, seek out and then provide the answer, or defer to expertise. Evaluate the environment of care and identify particular circumstances under which staff may be more likely to answer questions without confirmation of the answers. Use these circumstances to address the issue during training programs that incorporate group discussions, simulations, and role-playing. Clearly delineate what types of questions nonclinicians can answer and those that must be referred to a clinician.

• Management style. Enhance awareness among management about the impact their teaching or management style may have on staff behavior. They should demonstrate that staff should not be afraid to admit that they do not know all the answers.

Dr. Gaunt is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.

References

• Morris E. The anosognosic’s dilemma: something’s wrong but you’ll never know what it is (part 1). The New York Times website. http://opinionator.blogs.nytimes.com/2010/06/20/the-anosognosics-dilemma-1/?_php=true&_type=blogs&_r=0. Published June 20, 2010. Accessed May 12, 2015.
• Weick KE, Sutcliffe KM, Obstfeld D. Organizing for high reliability: processes of collective mindfulness. In: Sutton RS, Staw BM. Research in Organizational Behavior. Vol 1. Greenwich, CT: JAI Press; 1999: 81-123.