by Matthew Sterling (additional edits by FlightBridgeED)
In the fast-paced and high-stress world of air medical services, where every second counts, patient safety is paramount. However, a lingering challenge in this critical field is the reluctance of healthcare providers to voice their concerns or speak up when they notice safety issues. This reluctance can stem from various factors, including the hierarchical nature of healthcare organizations and the fear of repercussions for challenging decisions. In this article, we’ll explore how the innovative concept of the STOP card can empower air medical teams to overcome these barriers and prioritize patient safety.
Drawing Inspiration from Futball (aka Soccer)
For those who consider soccer the true “foot” ball, the sight of a game coming to a standstill with a referee holding up the despised Red Card is all too familiar. Usually, this is secondary to a player committing a foul on another player or an injury being delivered maliciously. Now, I know the argument is coming about Football vs. Soccer, but that is an argument for another day. For those not familiar with the game or concept, referees carry yellow and red cards during the game. Yellow cards are issued as a warning to players after an aggressive or non-deliberate violent act, and red cards result in immediate ejection from the game.
The Safety Time Out Procedure (S.T.O.P.) in Healthcare
The safety time-out procedure, or S.T.O.P., has been around since the American College of Surgeons began using it in 2003. This procedure is most commonly seen in the operating room (OR) suites before surgery to ensure that all parties present are aware of what procedure is being performed, plans, who is participating, and whether this was the correct patient, procedure, etc. Any safety concerns are brought up at that time before proceeding.
In pre-hospital and critical care transport medicine, similar checklists are supposed to keep healthcare providers on track, but even with the promotion of safety and Just Culture, providers still report they are not willing or even afraid to speak up if they see something. This reluctance can be attributed to differences in the level of the provider, someone’s position in the organizational structure, or because it is not commonplace at that service to speak up.
The Challenge of Speaking Up in Healthcare
Air medical services are inherently complex and demanding. As opposed to other industries, there are a lot of positions that sometimes have more than fifty applicants. Air medical is a wildly desirable position, and it’s easy to see why anxiety could be perceived by some employees when they realize their position could be filled by afternoon if they found themselves no longer employed.
The authority gradient, which often exists in such environments, can create a culture where questioning superiors is discouraged, even when it might be essential for patient safety. In air medical services, where teamwork and communication are vital, providers may worry that challenging a decision or pointing out a safety concern could lead to negative consequences. This fear can deter them from speaking up, even when they have valid concerns that could impact the safety of the mission.
Also, the intense emotional stress associated with pre-hospital and air medical services can further exacerbate the reluctance to speak up. In high-pressure situations, healthcare providers may be focused on immediate actions and hesitate to introduce potential conflict, fearing that it could disrupt the mission or result in mistakes.
Missed Safety Checks: Hesitation to speak up can lead to missed safety checks and overlooked critical steps in pre-flight preparations. These oversights can compromise the safety of the crew, the patient, and even the mission itself.
Delayed Interventions: In critical situations, any delay in recognizing and addressing a safety concern can have life-threatening consequences. Seconds truly matter in air medical missions, and hesitation can cost valuable time.
Team Dynamics: Effective teamwork and communication are essential for successful air medical missions. When team members are reluctant to speak up, it can erode trust and cohesion, hindering their ability to provide optimal care.
Safety Culture: A culture of silence undermines the development of a robust safety culture. Instead of learning from mistakes and focusing on continuous improvement, blame can take precedence, discouraging individuals from reporting errors or near misses.
The Importance of a Just Culture
Before we dive into how the STOP card can be a game-changer in addressing these challenges, it’s essential to understand the concept of a Just Culture. A Just Culture in Healthcare emphasizes a blame-free environment where errors and safety concerns are openly discussed, and individuals are held accountable for their actions while acknowledging that humans can make mistakes. It’s about fostering an environment where everyone is encouraged to report near misses and adverse events without fear of punishment but with a focus on learning and improving processes.
Empowering Air Medical Providers with the STOP Card
Recognizing and addressing the reluctance to speak up is crucial for enhancing patient safety in air medical services. The STOP card, inspired by the world of soccer, is a tangible and universally understood tool that can empower air medical teams to break the silence. Here’s how it works:
A Visual Reminder: The STOP card serves as a powerful visual reminder for all team members. Printed on the back of essential identification cards, it’s always within reach and view. This constant presence reinforces the importance of safety in the minds of air medical providers.
Empowerment to Speak Up: When any team member observes a safety concern or feels the need to pause and confirm critical steps in a mission, they can confidently present the STOP card. This act empowers them to initiate a safety pause, knowing that their concerns are valued.
Promoting Open Communication: The STOP card shifts the focus from hierarchy to patient safety. It encourages open communication and creates an environment where all team members feel comfortable voicing their concerns without fear of reprisal.
Mitigating Risks: Importantly, the STOP card also serves as a reminder that no air medical mission is without its risks, no matter how routine it may seem. It underscores the critical importance of mitigating these risks and ensuring the safety of both the crew and the patient.
In the high-stakes world of air medical services, where precision and teamwork are essential, the STOP card can be a game-changer. It provides a practical and immediate means of promoting open communication, accountability, and a culture of safety.
The STOP Card in Action
Let’s explore a hypothetical scenario to understand how the STOP card works in real-life healthcare settings:
Imagine a critical care transport team is preparing to intubate a patient during a high-stress emergency situation. The team is moving quickly, and the pressure is high. In the rush, a junior member notices that a crucial step in the intubation process has been overlooked.
In the traditional healthcare culture, this junior member might hesitate to speak up, fearing the repercussions or thinking that others have noticed the oversight. However, with the STOP card readily accessible on their badge, the junior member feels empowered. They confidently present the STOP card, signaling a pause in the procedure.
The team acknowledges the STOP card, and the error is quickly rectified. The intubation proceeds safely, with all team members on the same page. The junior member’s action not only prevented a potential patient safety issue but also reinforced the culture of open communication and Just Culture within the team.
Addressing the “First, Do No Harm” Dilemma
The folks over at TheFirst10EM.com put out an interesting but contentious article a few years ago on the notion of “Primum non nocere,” or “First, do no harm.” An important takeaway from it, regardless of which side of the argument you camp out on, is that there really aren’t many procedures in medicine that have no associated risks involved. Having the STOP card in the hands of every one of our providers not only gives them the reminder to speak up but also serves as a reminder that no procedure is without its risks, no matter how small it may be.
This addresses a fundamental dilemma in healthcare: the tension between the imperative to provide treatment and the imperative to avoid harm. The STOP card doesn’t eliminate risks, but it brings them to the forefront of awareness. It acknowledges that even seemingly routine procedures in air medical services carry inherent risks. By doing so, the STOP card prompts providers to be vigilant, stay focused on safety, and take the necessary precautions to minimize those risks.
In the dynamic environment of air medical services, where critical decisions must be made swiftly, the STOP card is a tangible reminder that safety should never be compromised, even in the face of urgency. It helps providers strike a balance between the urgency of providing life-saving care and the responsibility to ensure that care is delivered safely.
In the fast-paced and high-stress world of air medical services, the STOP card emerges as a practical and powerful tool. It serves as a visual reminder, an empowerment mechanism, and a safety catalyst. By bringing attention to the tension between providing urgent care and ensuring patient safety, the STOP card promotes a balanced approach where no procedure is exempt from scrutiny.
In the sky or on the ground, the STOP card reminds air medical providers that their primary commitment is to the safety and well-being of the patient. It encourages them to prioritize safety, communicate openly, and collaborate effectively, ultimately enhancing the quality of care delivered during every mission.
As the healthcare industry continues to evolve, the STOP card stands as an innovative solution to address the challenges of reluctance to speak up and the fundamental dilemma of balancing treatment with harm avoidance. It reinforces the idea that in air medical services, as in all healthcare, patient safety is non-negotiable, and silence should never be an option when it comes to ensuring the best possible outcomes for those in need.
1) Pellegrini, Dr. C. A. (2017, May 31). Time-outs and their role in improving safety and quality in surgery. The Bulletin.
2) Morgenstern, J. Stop saying “First, do no harm”, First10EM, July 20, 2020. Available at: