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  • Writer's pictureJeanette Zocco

Speaking Up for Safety

Updated: Apr 12

Safety Teamwork


The value of effective communication among team members cannot be emphasized enough. In fact, ineffective communication has shown to be a consistent root cause of errors and sentinel events in Joint Commission data (AHRQ, 2012). Speaking up for safety can be difficult depending on the circumstances, staff involved, receptivity of the individual(s) being questioned, and overall existing culture.  Structured communication tools can help guide conversations when there is concern for patient safety, an error is noted, or clarity is needed in a plan of care. The two-challenge rule and CUS are examples of communication strategies for safety (AHRQ, 2012). This article will discuss these tools in more detail. 

Two Challenge Rule

 The two-challenge rule is a method for communicating concerns respectfully. Concerns are voiced two times, either by one individual or by different team members. The first challenge involves asking a question. If the question is ignored, the second challenge involves asking for clarification with more information provided. The goal is for the individual being challenged to respond. If the individual doesn’t respond, then continued action is necessary to resolve the situation, including going to a supervisor or using the chain of command (AHRQ, 2012). For example, a nurse questions a doctor’s order for regular insulin 60 units. The first challenge is a question about the dosage. The second challenge gives more information: “Dr. Smith, we don’t typically give 60 units of regular insulin for sliding scale coverage.” The doctor responds, “I meant to give an order for 6 units.”


CUS is another safety advocacy tool and represents the following words: I am Concerned. I am Uncomfortable. This is a Safety issue (AHRQ, 2012). CUS provides a scripted conversation for a concerning situation. It allows any team member to “stop the line” or halt the situation until further clarification is received. For example: A patient is undergoing an elective induction of labor with oxytocin and is remote from delivery. The fetal heart tracing (FHT) displays interruptions in oxygenation despite intrauterine resuscitation measures to maximize oxygenation and uteroplacental circulation. Oxytocin was discontinued as per protocol. The nurse notifies the physician, who orders the oxytocin to be restarted.

Using the CUS tool, the nurse may respond, “I am concerned because the fetal heart tracing shows continued minimal variability and recurrent late decelerations despite efforts to correct these features with lateral positioning, 500 cc Lactated Ringers bolus, and discontinuation of the oxytocin. I’m uncomfortable with the plan to restart oxytocin because, according to our protocol, the FHT does not meet the oxytocin initiation checklist criteria. This is not safe.” The conversation may then be centered on an alternative plan.


(Reprinted with permission from AHRQ TeamSTEPPS 2.0 Pocket Guide)

Integrating Communication Tools into Practice

Speaking up for safety takes courage along with a supportive team. A multifaceted approach assists with successful integration of these tools into practice. Building a strong culture of safety and leadership support enables speaking up without fear of punishment or retaliation. The AHRQ TeamSTEPPS® program provides a solid foundation for establishing environments that are open and receptive to communication. Multidisciplinary simulation can be used to reinforce the behaviors and hard-wire the language. Real-time role modeling by leaders brings the tools into the clinical environment. 

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on Amazon, click below to access:

Copyright by Jeanette Zocco MSN RNC-OB, C-EFM, C-ONQS


Agency for Healthcare Research and Quality (2012). Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS®)  2.0. Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6. Mutual Support. (n.d.). Retrieved from

Agency for Healthcare Research and Quality (2013). Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS®) 2.0. Pocket Guide. Retrieved from

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