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A “Code Blue” is called when a patient on a medical-surgical ward is discovered pulseless and not breathing. The code team rushes in and begins CPR. “Does anybody know this patient?” the team leader barks as the team continues its resuscitative efforts. A few moments later, a resident skids into the room, having pulled the patient's chart from the rack in the nurse's station. “This patient is a No Code!” he blurts, and all activity stops.

As the Code Blue team members collect their paraphernalia, the patient's young nurse wonders in silence. After all, she received sign-out on this patient only a couple of hours ago, and she was told that the patient was a “full code.” She thinks briefly about questioning the physician, but reconsiders. One of the doctors must have changed the patient's code status to do not resuscitate (DNR) and forgotten to tell me, she decides. Happens all the time. So she keeps her concerns to herself.

Only later, after someone picks up the chart that the resident brought into the room, does it become clear that he had inadvertently pulled the wrong chart from the chart rack. The young nurse's suspicions were correct—the patient was a full code! A second Code Blue was called, but the patient could not be resuscitated.1

All organizations need structure and hierarchies, lest there be chaos. Armies must have generals, large organizations must have CEOs, and children must have parents. This is not a bad thing, but taken to extremes, these hierarchies can become so rigid that frontline workers withhold critical information from leaders or reveal only the information they believe their leaders want to hear. This state can easily spiral out of control, leaving the leaders without the information they need to improve the system and the workers believing that the leaders are not listening, are not open to dissenting opinions, and are perhaps not even interested.

The psychological distance between a worker and a supervisor is sometimes called an authority gradient, and the overall steepness of this gradient is referred to as the hierarchy of an organization. Healthcare has traditionally been characterized by steep hierarchies and very large authority gradients, mostly between physicians and the rest of the staff. Errors like those in the wrong DNR case—in which a young nurse suspected that something was terribly wrong but did not feel comfortable raising her concerns in the face of a physician's forceful (but ultimately incorrect) proclamation—have alerted us to the safety consequences of this kind of a hierarchy.

Teamwork may have been less important in healthcare 50 years ago than it is today. The pace was slower, the technology less overwhelming, the medications less toxic (also less effective), and quality and safety appeared to be under the control of physicians; everyone else played a supporting role. But the last half century has brought a sea change in the provision of ...

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