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Patient safety is a core focus now in medical education, with an increasing number of training programmes educating learners about its key tenets.1–3 Residents now undergo formal training about the importance of contributing to a culture of safety by speaking up to avoid errors or harm, but still face difficulties enacting these behaviours in practice.4 In this issue of the journal, Martinez et al have attempted to tease out differences in speaking-out behaviours between traditional and professionalism-related patient safety threats.5 The authors have raised several interesting points worthy of further exploration. In this editorial we focus on unprofessional behaviour as a potential threat to patient safety and propose some new ways of thinking about how to integrate research and lessons from both the patient safety and professionalism literature.
In the study by Martinez and colleagues, residents reported witnessing unprofessional behaviour more frequently than they observed patient safety breaches (75% vs 46%; p<0.001).5 They also reported speaking up less frequently about unprofessional behaviour than about traditional safety threats (46% vs 71%; p<0.001) despite their view that this is important for patient safety. When participants were faced with two safety scenarios (one meant to represent a traditional threat to patient safety and one focused on unprofessional behaviour), the same pattern was seen. The authors suggest that professionalism-related safety threats are more difficult to speak up about because, among other things, they are perceived to be more deliberate and more likely due to character flaws and thus are less likely to change even if reported.6 7 Residents were also concerned about alienation from the team and potential for retaliation. The authors focus on two instruments that assess the ‘culture’ for safety and reporting, and conclude that measuring the environment could draw our attention to units or teams that …
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