Understanding authority gradient: tips for speaking up for patient safety (and how to enhance the listening response)

Key content Up to one‐third of healthcare personnel still have concerns about speaking up when they notice potential errors. Cultivation of a shallow authority gradient encourages trainees to clarify instructions, challenge decisions and voice concerns, thereby reducing ambiguity and potential errors. Senior doctors should support junior team members who raise concerns by encouraging a working environment that is effective and safe. Aviation, rail and maritime industries recognise that steep authority gradients can lead to reluctance to escalate, resulting in near misses and fatalities. Learning objectives To understand the difference between hierarchy and authority gradient. To learn how graded assertiveness techniques such as ‘advocacy and inquiry’, PACE and CUSS can be used as non‐confrontational tools to speak up. To understand that senior doctors should practise active listening and have insight into their own openness when challenged.