Medical errors are a leading cause of death in the United States. Effective communication and speaking up are crucial factors in patient safety initiatives. We examined the reasons reported by pediatric residents for not speaking up about safety events when they are observed in practice. We also tested a priori hypotheses of associations between categories of barriers to speaking up with perceptions of safety and teamwork culture.


Pediatric residents completed an anonymous electronic survey measuring safety and teamwork culture along with an open-ended question asking them to list the top 3 barriers to speaking up about patient safety concerns. Researchers independently coded the open-ended responses to identify themes, which were then categorized into a published framework. Data were collected in 2013 (response rate = 46%) and 2014 (response rate = 62%).


The most common reported barriers to speaking up were as follows: perceived personal safety of speaking up (consequences, intimidation, and hierarchy concerns), individual barriers (communication skills and confidence), perceived efficacy of speaking up (feeling powerless), and contextual factors (high workload). Residents who reported barriers relating to efficacy of speaking up reported lower safety culture scores in 2013 and 2014. Residents who reported barriers related to safety reported lower teamwork culture scores in 2013.


Pediatric residents reported individual barriers, personal safety concerns, lack of efficacy, and contextual factors as reasons to not speak up about patient safety. Concerns about the safety of speaking up and the efficacy of speaking up were correlated with teamwork and safety culture, respectively.

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