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Difficulty: MediumInterprofessional Teamwork and Conflict Resolution

A 72-year-old woman is admitted to the intensive care unit with septic shock secondary to severe community-acquired pneumonia. She is currently hypotensive despite adequate fluid resuscitation, necessitating the initiation of a norepinephrine infusion. The critical care fellow prepares to insert a central venous catheter into the right internal jugular vein. As the fellow establishes the sterile field, the bedside nurse observes the sleeve of the fellow's sterile gown inadvertently brush against the non-sterile bed rail. The nurse promptly informs the fellow of the breach. The fellow dismisses the concern, stating, 'It was just a graze, and we cannot afford to waste time setting up again given her hemodynamic instability.' Which of the following is the most appropriate next step in communication for the nurse?

  1. Clearly voice the safety concern a second time, specifically stating discomfort with proceeding using contaminated equipmentAnswer
  2. B
    Conclude that the fellow has correctly weighed the risks and benefits, and cease further objections to the procedure
  3. C
    Halt the procedure and leave the patient's bedside to personally retrieve a new sterile kit from the central supply room
  4. D
    Suggest immediately transferring the patient to the operating room where the line can be placed under stricter sterile conditions
  5. E
    Step away from the sterile field and immediately initiate a retrospective Root Cause Analysis regarding the equipment contamination

Answer

The most appropriate next step is to clearly voice the safety concern a second time, utilizing structured language to express discomfort with using contaminated equipment.
The correct action demonstrates the use of the Two-Challenge Rule combined with the CUS (I am Concerned, I am Uncomfortable, this is a Safety issue) framework. In high-reliability healthcare organizations, any team member is empowered to 'stop the line' if a patient safety threat is identified. If an initial concern is dismissed, the protocol requires the team member to assertively state the concern a second time. If the second challenge is also dismissed, the team member must escalate the issue through the formal chain of command.

Step-by-Step Solution

1
Identify the patient safety threat.
A sterile breach occurred during the preparation for a central venous catheter insertion, posing a high risk for a central line-associated bloodstream infection (CLABSI).
Maintaining strict sterile technique is paramount during central line placement to prevent iatrogenic infections.
2
Evaluate the initial communication attempt.
The nurse successfully raised the initial concern, but the physician dismissed it due to perceived time pressure.
Interprofessional conflicts often arise when team members prioritize different aspects of care (e.g., speed of hemodynamic stabilization versus infection control).
3
Apply standardized conflict resolution frameworks.
The nurse must use the Two-Challenge Rule and the CUS (Concerned, Uncomfortable, Safety) framework to reassert the concern.
When an initial safety warning is ignored, standard high-reliability protocols mandate voicing the concern a second time to ensure it is fully understood before escalating through the chain of command.

Key Concept

The Two-Challenge Rule dictates that team members must assertively voice a patient safety concern at least twice if the initial assertion is ignored or dismissed.
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Topics

Interprofessional Teamwork and Conflict Resolution

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