Raise the Index of Suspicion to Safeguard Patients

Disruptive behaviors, intimidation in the workplace, and a culture of disrespect among health care professionals have repeatedly surfaced as significant barriers to patient safety. The hierarchical nature of patient care and the autonomy with which health care professionals have been taught to practice set the stage for a culture that does not respond well to even the slightest queries about possible problems with patient care. However, there’s a less obvious but no less dangerous risk related to the culture that often goes unnoticed until a serious adverse event happens: staff or patients do speak up about potential concerns, but they are too easily convinced that their concerns are unfounded.

When a person voices a concern, there may not be disruptive, disrespectful, or obvious intimidating behavior involved per se, but rather an explanation from competent practitioners that dispels the initial concern too quickly, before it has been given sufficient consideration. A pharmacist reassures a technician that the compounding directions are correct when questioned about an unusual volume of ingredients; a pharmacist reassures a patient that the medication is correct when questioned about its appearance; a physician convinces a pharmacist that the prescribed dose is correct when questioned because it differs from a protocol—these all-too-frequent examples have led to fatal adverse drug events. Those who questioned the patient’s care were easily convinced that others knew more than they did, particularly if the provider who was questioned had an otherwise stellar reputation. What is needed to safeguard patients is an appropriately high index of suspicion for errors.

An index of suspicion is defined as “awareness and concern for potentially serious underlying and unseen injuries or illness.”¹ Suspicion is defined as “the act or an instance of suspecting something wrong without proof or on very slight evidence, or a state of mental uneasiness and uncertainty.”² A high index of suspicion requires consideration of a large differential so that a serious possibility is not accidentally discounted; a potential medical error should always be considered one of the possibilities. An appropriately high index of suspicion should lead a person with a concern to pursue it until it’s proved not to be a credible patient threat, even when met with opposition from experts. A high index of suspicion should also prompt the provider to be responsive to voiced concerns, from patients and other practitioners, and to initiate a suitable investigation to determine if there is a credible threat to the patient.

To improve patient safety, health care needs to raise the index of suspicion for errors, always anticipating and investigating the possibility when any person, regardless of experience or position, voices concern or when patients are not responding to treatment as anticipated. Functional patient care teams, in which every person’s perspective, skills, knowledge, and observations are considered important and worthy of mention and investigation, must be developed. Staff members need to be mentored on how to resolve potential concerns and to trust in their own experiences to augment the expertise of others.

All health care practitioners need to encourage and be receptive to staff and patients who ask questions, even if staff or patients just have a sense that “something” is wrong or they can’t articulate the concern well. Health care practitioners need to ensure that concerns are not only raised but also properly investigated and addressed. You can be sure that those involved in serious errors wish that they had taken the opportunity to do just that.

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

References:

• American Academy of Orthopedic Surgeons. Emergency Care and Transportation of the Sick and Injured. 10th ed. Sudbury, MA: Jones and Bartlett Learning; 2010:747.
• Merriam-Webster [online dictionary]. www.merriam-webster.com/dictionary/suspicion. Accessed May 29, 2014.