■ Physician-team:

Leveraging the power of collaboration to foster safe care

Lack of graded assertiveness in dosing error

Published: August 2021

Type of activity: Video

Activity summary

The short video "Lack of graded assertiveness in dosing error" portrays a patient safety dilemma for 2 medical students and a nurse. The facilitation questions and suggestions to faculty focus on helping learners to think about their professional roles and responsibilities as members of a hierarchical healthcare team.


Setting: Emergency department, side desk, away from the nursing station in front of a computer workstation.

Dr. Smart: So, what is remarkable on this chest x-ray? (Pauses only a second before answering his own question.) The answer I am waiting for is that the mediastinum looks wide. So this patient is going to need an urgent CT angio to rule out an aortic dissection. I don't suppose either of you have the remotest idea on how to order a CT scan? So I'll have to show you ...

Louise: Dr. Smart, I'm sorry to interrupt, but the 74-year-old patient in bed 3 is having more back pain. He says it's up to an 8 out of 10 now. Can he have something more for his pain?

Dr. Smart: Just give him morphine 5 mg IV, Louise

Louise: He's received a total 10 mg of morphine over the past 2 hours and it doesn't seem to be working. What about giving him hydromorphone instead?

Dr. Smart: Hmmm, I am not used to ordering that, so let me check (pulls out his smartphone). Let's see ... hydromorphone ... (becomes annoyed after scrolling for a few seconds). Ahh great, the subscription on my app ran out. Well listen, just give him hydromorphone 5 mg IV.

Medical students: (looking at smartphone and whispering to each other)
#1: Hey, that dose seems really high for this patient.
#2: Yeah, you're right. You should say something about it.
#1: Not me. Maybe the nurse will say something?
#2: No, you looked it up, you should say it.

Louise: (re-reads order) All right, so we're going to give him hydromorphone 5 mg IV. I'll let you know if I need anything else. Thanks, Dr. Smart.

Dr. Smart: Right, now back to more pressing matters. Let's get on with ordering that CT scan. Now could one of you page the radiology resident? It's 209.

Med student #1: (hesitantly) Excuse me, Dr. Smart. I was checking my drug reference, and it says that the recommended dose for hydromorphone is lower than what you ordered.

Dr. Smart: (somewhat dismissive) It's going to be fine. Listen, that patient just got 10 mg of morphine and didn't touch him. Let's just hope that radiology resident calls back quickly so we can book our CT scan.

Concluding facilitation question: What alternate courses of action could the students and nurse have taken?

Facilitation questions

  1. What other strategies could the medical student(s) try next?
  2. Does the nurse have a responsibility to speak up in this situation? Discuss.

Suggestions to faculty

The video shows a nurse asking an attending physician to write an order for opioid analgesia, while 2 medical students observe the interaction. The nurse and medical students are concerned about the dose that is prescribed but are unsure how to bring their concerns to the attention of their supervisor. During the debriefing, discuss with learners possible approaches to successfully speaking up, including graded assertiveness, the two-challenge rule and the CUS and CHAT mnemonics.

Additional suggestions:

  1. Have learners work in pairs to role-play a conversation in which the medical student tries to raise their concerns with the attending physician.
  2. Run a simulation with 1 or 2 learners and a standardized actor playing the role of the attending physician (could also have another learner or actor play the role of the nurse).
  3. Assign learners in small groups to prepare a demonstration using one of the approaches to speaking up, which could then be shared with the larger group.

Additional resources

CanMEDS: Collaborator, Professional

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.