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Observations and Lessons Learned on the Journey to High Reliability Health Care.

Revisiting disruptive and inappropriate behavior: Five years after standards introduced

Oct 02, 2013 | 53800 Views

By Ronald M. Wyatt, M.D., M.H.A.,
Medical Director
The Joint CommissionRonald Wyatt, Medical Director, The Joint Commission

While most care providers, particularly physicians, adhere to the highest professional standards of behavior, a small number do not, and some recurrently display disruptive or intimidating behavior. In 2008, The Joint Commission became so concerned about “behaviors that undermine a culture of safety” that it issued a Sentinel Event Alert on the topic and developed a Leadership standard requiring all hospitals to have a code of conduct as well as a process for managing disruptive and inappropriate behaviors. Now there is compelling evidence that some behaviors contribute directly to medical errors. This was a prominent finding in Rosenstein and O’Daniel’s work,1 in which respondents commonly indicated a reluctance to call or interact with certain doctors to clarify or question orders for fear of provoking a hostile response.

According to the Institute of Safe Medication Practices (ISMP) survey on workplace intimidation, 17 percent of respondents had felt pressured to accept a medication order despite concerns about its safety on at least three occasions in the previous year; 13 percent had refrained from contacting a specific prescriber to clarify the safety of an order on at least 10 occasions; and 7 percent said that in the previous year they had been involved in a medication error where intimidation played a part.2

While disruptive and intimidating behavior can be displayed by nurses, pharmacists and managers, it is the behavior of doctors which most often causes problems, perhaps because medical culture has had a history of tolerance or indifference to this, or because organizations have tended to treat doctors differently from other staff.3

In its Sentinel Event Alert, The Joint Commission describes disruptive and intimidating behavior as including “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities,” and it goes on to say that “intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation and impatience with questions.”3

All definitions recognize that disruptive and intimidating behavior occurs along a spectrum of intensity and frequency and that recurrent disruption by a small number of individuals is the most common pattern.

The 1999 Institute of Medicine (IOM) report “To Err is Human”4 – widely regarded as the document which launched the modern patient safety movement – recognized that although most efforts to improve safety should focus on reducing system failures, individual professionals’ “dangerous, reckless or impaired” behavior can also sometimes harm patients (page 169). We now accept that most errors are committed by “good, hardworking people trying to do the right thing,” and that to improve patient safety we should focus on designing systems which ensure a safe culture rather than trying to identify who is at fault.5

While the most compelling reason for addressing disruptive and intimidating behavior has been the clear demonstration that it can be harmful for patients,1,2 there are other reasons. Individuals who have a history of disruptive behavior also pose the highest litigation risk for American hospitals, and many would argue that such behavior is inconsistent with the highest professional standards.6,7,8 Such behavior also contributes to poor teamwork, difficult work environments, poor patient satisfaction, and problems recruiting and retaining nursing staff.3

Several groups have described approaches for dealing with disruptive and intimidating behavior; the ones which seem most adaptable are those from the College of Physicians and Surgeons of Ontario and the Vanderbilt group.9,10,11 These include:

  • Making expectations explicit by having a code of conduct supported by appropriate policies
  • Ensuring robust Board support for clinical leaders in implementation
  • Support and training for those dealing with disruptive and intimidating behavior
  • Screening for health and personal issues
  • Proactive surveillance systems
  • Dealing consistently and transparently with infringements
  • Dealing with lower level aberrant behavior early
  • Having a graduated set of responses (informal, formal, disciplinary, regulatory) depending on the severity of the incident
  • Making resources available to help those displaying and those affected by disruptive and intimidating behavior

1 Rosenstein AH, O’Daniel M: A survey of the impact of disruptive behavior and communication defects on patient safety. The Joint Commission Journal on Quality and Patient Safety, August 2008:34(8)464-471
2 Institute for Safe Medication Practices: Intimidation: practitioners speak up about this unresolved problem (Part 1). ISMP Medical Safety Alert! March 11, 2004, (accessed September 13, 2013)
3 Joint Commission: Behaviors that undermine a culture of safety. Sentinel Event Alert, July 9, 2008:40, (accessed September 16, 2013)
4 IOM Committee on Quality of Health Care in America: To err is human: building a safer health system. National Academy Press, Washington, D.C., 1999
5 Wachter RM, Pronovost MD: Balancing “no blame” with accountability in patient safety. New England Journal of Medicine, October 1, 2009:361(14):1401-6
6 Hickson GB, et al: Patient complaints and malpractice risk. Journal of the American Medical Association, June 12, 2002:287(22):2951-7
7 Healy GB: Competence, safety, quality. Bulletin of the American College of Surgeons, December 2007:92(12):9-12
8 Leape LL, Fromson JA: Problem doctors: is there a system-level solution? Annals of Internal Medicine, January 17, 2006:144(2):107-15
9 College of Physicians and Surgeons of Ontario: Guidebook for managing disruptive physician behavior. Toronto, 2008, DPBI Guidebook(1).pdf (accessed September 16, 2013)
10 Hickson GB, et al: A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine: Journal of the Association of American Medical Colleges, November 1982:(11):1040-8 (accessed September 16, 2013)
11 Swiggart WH, et al: A plan for identification, treatment, and remediation of disruptive behaviors in physicians. Frontiers of Health Services Management, 2009:25(4):3-11

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Comments (3 Comments)

SOM_RN - Salt Lake City, UT
To lars aanning, who has never seen an adverse patient event from a so-called 'disruptive' physician. I am wondering why it is that you do not see a problem with, or want to consider the word 'disruptive' when referring to a physician who snaps at a resident, nurse or medical student when they ask a question or want clarification. Or how you can possibly not recognize the correlation? As the original JC SEA #40 clearly states, 40% of clinicians admitted to remaining quiet or passive during patient care events rather than question a known intimidator. Those were clinicians. That means that your colleagues are admitting that because of the behaviors displayed, they do not want to speak up and question you because of your possible reaction. The stories go on and on....residents that are berated for 'stupid questions', then don't ask and make an error, causing the patient to pay the consequences. Nurses who are yelled at and humiliated for asking for clarification, articles on why bully doctors are bad doctors, etc etc.
I will agree with you on one point: Some of the most disruptive are also some of the nicest-to their patients. But to those of us who work behind the scenes? They won't be the physician that we recommend. Why? We know that when that patient goes to sleep in the OR, or the patient door in the clinic closes, those characteristics come out. And I wouldn't put anyone I know or love in the hands of someone who does not make it safe to question.
5:35 PM Jul 1st

Lee RN-C
I have been a nurse for 35 years, and those years, I have been subjected to countless instances of physicians suffering from "God Syndrome". I know of at least a dozen instances I can recall sitting here where a patient has suffered either significant morbidity, or mortality secondary to a "disruptive" physician. Nurses in particular are very well aware who the "disruptive" physicians are, and I dare say many nurses will make sure there is always a "Plan B" in effect to ensure patient safety when one of those physicians is on call after hours.
In my own case, I've learned to document potentially dangerous interactions with said physicians with great detail and care. I stress to my newer nurse co-workers the importance of crystal clear, detailed documentation. I also ensure my family members have no contact with physicians I know are holier-than-thou, and prone to intimidating staff rather than admit errors or lapses in judgement. Finally, I have developed a cast iron rear-end over the years. The last time a disruptive physician threatened with the Wrath of God for questioning a clearly inappropriate medication order, I simply shrugged and said, "Knock yourself out."
10:00 PM Oct 13th