Dear Subscriber,

It’s the stuff legends are made of: a brilliant, demanding surgeon with patients coming to him from around the world for his extraordinary skill loses his patience in the operating room — throwing a pair of scissors that won’t cut at a nurse, narrowly missing her. He then calls another nurse “lame-brain” and “an idiot” for not being better prepared, and vents his frustration at the whole OR team.

Increasingly, research suggests that swearing, yelling, and throwing objects by physicians are putting patients at risk by increasing the likelihood of medical errors, according to an article inThe Boston Globe.

The Joint Commission, the national organization that accredits healthcare systems, issued a safety alert to hospitals in July, saying outbursts threaten patient safety because they prevent caregivers from working as a team.

And setting a precedent, the Joint Commission is requiring all hospitals, nursing homes, and other healthcare facilities to adopt "zero-tolerance" policies by January 1, 2009, including codes of conduct, ways to encourage staff to report bad behavior, and a process for helping and, if necessary, disciplining offenders, according toThe Globe.

Let’s put this in a workplace context.

Manager, supervisor and especially line employee behaviors have been under the microscope at many worksites for years now, thanks to the popularity of behavior-based safety programs.

But what happens — really — when one of your employees at your worksite is observed performing an at-risk behavior. OK, he or she is probably not throwing scissors at someone. Maybe they’re wearing their goggles or respirator around their neck when they should be firmly in place. Perhaps lockout-tagout procedures are skipped. Or a manager or supervisor is yelling, threatening, bullying and cursing an employee or group of employees.

What are the odds at your workplace someone will step forward and confront the individual and his or her at-risk behavior on the spot?

Or will the observation of dangerous, out of line behavior be formally reported?

Does your workplace have an official “zero tolerance” policy, like hospitals are being forced to adopt, which includes conduct codes, reporting systems, and discipline if necessary?


Industry, which is 10-15 years ahead of healthcare in observing and reporting on at-risk behaviors, still wrestles with the challenge of standing up and speaking up to at-risk behaviors.

This includes rude, boorish and bullying verbal behavior, many times coming from supervisors and managers. Drinking or abusing drugs on the job. Flashes of violent outbursts and threats that could be preludes to tragic rampages. Risky horseplay and short-cuts. Cutting compliance corners. Sleeping through training classes. Poor lifting techniques, straying into the line of fire, even something as simple as constantly running up and down stairs or ignoring trash on the floor.

Is anything said, or reported?

Whether it is or not brings us back to one of the most popular safety and health topics of the day — culture. For instance, most hospital cultures have a tradition of tolerating abusive behaviors to placate high-intensity surgeons, according toThe Boston Globearticle.

Industry has its organization charts, making it tough for a line employee to call out a manager for abusive language. Healthcare has something more intimidating, called the “authority gradient,” which has been ingrained in hospitals seemingly forever.

It’s a very steep gradient, with physicians and surgeons at the top, operating very often literally with near-impunity due to their authority, schooling, skill at saving lives, and ability to make money for the institution. Further down the hierarchy are the nurses, nurses aides, lead technicians, materials technicians, and others on the OR team or in various departments. Tradition calls for deference to the surgeon, especially during the intensity of the surgical procedure. As for reporting incidents after the fact, hospitals’ long-standing “walls of silence” most often cover-up behavior that led, or could have led to medical errors and patient harm.

And we’re not limited to talking about the operating theatre here. The Joint Commission cites several studies linking bad behavior to medical errors outside the OR. One survey found that some nurses and pharmacists had avoided consulting with a prescribing doctor because they did not want to interact with that particular doctor, according toThe Globe’sreport.

Does your workplace culture silently adhere to its own authority gradient? Or have you been able to build a culture of trust, encouraged caring, perhaps anonymous observation reporting, and overall open and honest communication between all levels of the organization?


Policies to address and rectify at-risk behavior are just emerging in healthcare. Patient safety experts say a key issue is making sure staff members are comfortable reporting colleagues' outbursts without fear of retaliation.

"These incidents happen because the OR environment is so high stress," said Dr. Marc Rubin, chairman of the surgery department at Massachusetts’ North Shore Salem Hospital, inThe Globearticle. "Surgeons hold patients' lives in their hands, yet they're dependent on equipment and people who are outside their control.”

Most hospitals don't track how many doctors, nurses, and other employees engage in disruptive behavior. Does your workplace track at-risk (and positive) safety-related behaviors?

Administrators at Vanderbilt University Medical Center estimate that four to six percent of doctors and nurses have repeated outbursts, according toThe Globearticle. Have you found it tends to be the same small group of employees, supers and managers who repeatedly flaunt behaviorial expectations?

Vanderbilt, which has one of the most extensive programs to track and deal with such behavior, began focusing on the problem a decade ago when administrators found that physicians who were sued often were more likely to have abusive outbursts. The medical center now advises 34 healthcare facilities on addressing the problem.

Can you link or document a connection between repeated at-risk behavior and dollar losses? That’s a major challenge in industry, which has the workers’ comp shield protecting the company, not malpractice worries.


But many workplaces and healthcare facilities share one burden: growing financial pressures amid dwindling resources and the threats of downsizing and consolidation that weigh on employees’ minds, elevate stress levels, and can lead to at-risk outbursts or behaviors.

"You're looking at a very stressed out industry," David Yamada, a Suffolk University law professor who specializes in employment issues including workplace bullying, said in the article, referring to healthcare. "You have an industry in crisis where people are having to do much more with limited resources. That combination can be a potent one."

But you already knew that, right?


There’s another challenge industry shares with healthcare: focus more attention on the behaviors that lead to near-misses, injuries or in the case of healthcare, medical errors; encourage your staff to report bad behavior more often; and executives might see reporting numbers escalate and call for harsh measures, like “zero tolerance” codes.

Beware of these pitfalls of a “zero tolerance” policy, cited by safety consultant DJ Borbidge, before introducing one to your culture:
  • Often violations are narrowly defined, allowing for no extenuating circumstances.
  • Many employees are reluctant to come forward to “rat” on violators either because there is a lack of trust that enforcement will be taken or conversely, they consider the policy extreme and become fearful.
  • Sometimes, this emphasis on reporting opens the door for an employee to get back at someone he/she does not like.
  • It is nearly impossible for management/supervision to catch all or even most acts of misconduct. Many incidents slip through the cracks.
  • The word “intolerance” itself is a strong catalyst for fear. Extensive research strongly indicates that “fear in the workforce” rarely increases productivity, quality or safety.
Take a look at your workplace culture. Are there “walls of silence” that inhibit confronting or reporting at-risk behavior? Is there an authority gradient that goes unchallenged? Can you document the consequences of inaction?


You might want to conduct a perception or climate survey to get some answers from the line troops. Healthcare is ahead of industry in its acceptance and growing use of perception surveys as cultural learning tools. You can find out about trust levels in your organization, fear levels, what employees really think about reporting and communication systems.

And you can learn perhaps how much work you have to do to create a culture that prioritizes addressing at-risk behaviors. That can include policies with teeth, reporting and communications systems with integrity, and training and coaching sessions on building inter-personal skills to tackle the difficult challenge of confronting bad behavior at all levels of the organization.