Collaborative Care

Safeguarding patients: The courageous communication solution

Preventable medical errors account for 440,000 deaths each year and are the third leading cause of death in the United States. According to The Joint Commission, communication failure is the third most commonly identified root cause of all sentinel events. A 2005 study titled “Silence Kills: The Seven Crucial Conversations in Healthcare” reported that more than half of 1,700 nurses, physicians, clinical care staff, and administrators witnessed coworkers “break rules, make mistakes, fail to support others, demonstrate incompetence, show poor teamwork, act disrespectfully, or micromanage.” Yet, the study states, “despite the risks to patients, less than 10% of physicians, nurses, and other clinical staff directly confronted their colleagues about their concerns.”

Building skills for courageous conversations

So how do you get a colleague’s attention when you have a safety concern? The Department of Defense partnered with the Agency for Healthcare Research and Quality (AHRQ) to develop a teamwork and communication system to improve safe healthcare delivery. Called TeamSTEPPS, this evidence-based framework optimizes team performance across the healthcare delivery system.

One TeamSTEPPS tool, called CUS, serves as an effective verbal alarm, empowering healthcare providers to “stop the line.” When you speak the signal words of the CUS tool—Concern, Uncomfortable, Safety—you alert team members and cue them to clearly understand not just the issue but also its magnitude or severity.

Here are the CUS steps:

1: State your Concern.

2: State why you are Uncomfortable.


3: State that this is a Safety issue. Identify why it’s a safety issue and state what actions you think should be taken.

CUS in action

Billy Evans, age 4, has a history of Type 1 diabetes. After an episode of uncontrolled blood glucose, he’s admitted to the pediatrics unit. Later, although his blood glucose level has nearly stabilized, his pediatrician wants to delay his discharge until the afternoon, just to be sure his blood glucose remains stable.

At the scheduled time for his insulin injection, his nurse Joanne prepares his injection. Her coworker, nurse Bonnie, approaches her, stating, “Joanne, the amount of fluid in that syringe looks quite large for Billy’s insulin dose. How much insulin are you preparing to give him?” Joanne replies,“10 units.” Bonnie uses the CUS tool to express her concern.

Bonnie: “I’m CONCERNED that you may be giving him too much insulin.”

Joanne: “Why do you think that?”

Bonnie: “It’s not uncommon to give adults with diabetes 10 units or more—but Billy’s a child and much smaller than an adult. What’s his blood glucose level now? I’m UNCOMFORTABLE because 10 units could cause severe hypoglycemia.”

Joanne: “I have to hurry and get this done.”

Bonnie: “This is a SAFETY issue. I really need you to stop what you’re doing and double-check the order.”

Joanne puts down the syringe, goes to the computer, and pulls up Billy’s chart while Bonnie doublechecks the insulin vial. They both want what’s best for Billy.

Caring Feedback Model

To improve both patient safety and satisfaction, staff at every level of a healthcare organization should hold each other accountable to high standards of care. In addition to the CUS method, you can use the Caring Feedback Model to give colleagues feedback about their actions (or inactions) that have safety consequences. Using this model helps people hear your feedback with less defensiveness, because they hear your caring coming through. (See How to use the Caring Feedback Model.)

CUS and the Caring Feedback Model in action

Joe Wilson, age 41, has a history of hypertension. After a recent myocardial infarction (MI), he comes to the cardiology clinic for follow-up care. An electrocardiogram (ECG) shows no evidence of changes, although his blood pressure is a little high. All of his other vital signs are normal, so Dr. Ross is ready to let Mr. Wilson go home—until he has the following conversation with Tracy, RN.

Tracy: “Dr. Ross, Mr. Wilson is complaining about tightness in his chest. He appears to be in some pain and his blood pressure is 170/90. He told me he takes several nitroglycerin tablets every day for chest pain. I’m CONCERNED his cardiac status is unstable.”

Tracy is expressing her concern that the patient’s condition is a safety issue.

Dr. Ross: “I hear you, but his ECG shows no ischemic changes, his oxygen saturation is good, and he’s not short of breath.”

Dr. Ross isn’t concerned at this point.

Tracy: “I’m uncomfortable letting him go home alone now.”

Tracy is taking her concern to the next level, expressing her discomfort.

Dr. Ross: “I understand. We could always let him go home with instructions to call the office tomorrow if he’s having any problems.”

Dr. Ross is starting to recognize the potential problem and offers a solution.

Tracy: “I’m concerned he might be having symptoms of another MI, since he’s having pain and his blood pressure is elevated. I’m UNCOMFORTABLE letting him go home because he lives alone and it would be a SAFETY issue if his pain worsens. I really need you to reevaluate him more closely before letting him leave.”

Tracy restates her concern for the patient’s safety and expresses her discomfort with Dr. Ross’s solution.

Dr. Ross: “You might be right. Let’s get some STAT blood work to be sure Mr. Wilson is safe to go home.”

Tracy: “Thanks, Dr. Ross. We’d both feel terrible if something happened that we could have prevented. I’ll let Mr. Wilson know we want to keep him here until we see his lab results.”

Expanded CUS format

Using an expanded CUS format that includes the Caring Feedback Model helps you express appreciation, identify consequences of failing to address the safety concern, convey empathy, and offer a suggestion. (See Combining CUS with the Caring Feedback Model).

Using the powerful feedback process with your team

With your management team or work team, engage colleagues in planning caring feedback so they can become more comfortable with the language involved. Start by creating a two-column worksheet with each step of the Caring Feedback Model and the CUS steps listed in the left column. In the right column, provide space for effective language to accomplish that step. Next, have team members work with a partner on one of the situations below.

Situation 1: You overhear a staff member say to a patient, “I know who you are. I won’t bother you with all those redundant questions.”

Situation 2: A staff member tells a patient, “Look, we’re really busy. We’ve had several people call out, and we don’t have enough staff.”

Situation 3: You overhear an RN say to a nursing assistant, “You’re great at inserting urinary catheters. I trust you. So please go into Mrs. Smith’s room and put her catheter in, OK? I have your back if someone complains.”

Situation 4: Dr. Jones leaves your unit after seeing Mrs. Smith. You ask him if he ordered pain medication for her severe back pain. He replies, “I’m on my way to the operating room and I don’t have time to go back to the unit and enter that order. So just go into the electronic health record and enter the medication as a phone order from me.”

Situation 5: A transporter arrives on the nursing unit with a patient to be admitted from the emergency department. A nurse who sees the patient coming says to a coworker, “Oh no! Another admission!”

Finally, invite team members share their caring feedback language with the whole group.

Courageous communication: The key to patient safety

When you combine the evidence-based approaches of CUS and the Caring Feedback Model, you engage in powerful, compassionate, direct communication that improves patient safety and helps you and your colleagues fulfill your caring mission.

Amy Steinbinder is vice president of nursing, evaluation,and quality with Language ofCaring®, LLCin St Louis, Missouri. All names in scenario are fictitious.

Selected references

Agency for Healthcare Research and Quality. TeamSTEPPS 2.0. ahrq.gov/professionals/education/curriculum-tools/teamstepps/ instructor/index.html

Joint Commission, The. Sentinel Event Data. Root Causes by Event Type: 2004 – 3Q 2015. http://goo.gl/W11V2f

Leapfrog Group. Hospital Safety Score: Hospital Errors Are the Third Leading Cause of Death in U.S., and New Hospital Safety Scores Show Improvements Are Too Slow. October 23, 2013. http://goo.gl/DIS6Pm

Maxfield D, Grenny J, Lavandero R, Groah L. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough to Save Lives. 2011. www.aacn.org/wd/hwe/docs/the-silent-treatment.pdf

Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Silence Kills: The Seven Crucial Conversations for Healthcare. 2005. silenttreatmentstudy.com/silencekills/

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2 thoughts on “Safeguarding patients: The courageous communication solution”

  1. Paul Albers says:

    Proud to have been a part of implementing these tools into practice. Excellent communication tool.

  2. Amanda says:

    Thank you for posting this information. I think it is crucial that communication be standardized across healthcare professions. Regardless of job title, it is important to be able to share critical information in a succinct, but effective manner. I have witnessed several preventable mistakes in healthcare due to poor communication, or lack thereof. I think it would be beneficial to teach CUS skills during orientation of a new healthcare job, and in annual/semi-annual skills days on units. If CUS was practiced in a role play setting, I feel that more healthcare workers would be comfortable communicating crucial information, leading to better outcomes with our patients.

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