Patient Safety Behaviors: Praise to Criticism Ratio

AstionBy Michael Astion, MD, PhD
Editor-in-Chief, Patient Safety Focus

Hundreds of hospitals across the United States have embarked on error prevention training as one component of a comprehensive approach to improving patient safety. Controlled trials examining the efficacy of error prevention training in healthcare are difficult to carry out and therefore lacking, but there is still reason to believe in the training. Evidence comes from results of individual hospitals and healthcare systems that have implemented the training as part of a comprehensive approach to patient safety, sustained the error prevention behaviors, and reduced their rates of serious safety events (1). Belief in error prevention training is also reinforced by low error rates in other industries, like nuclear power, that use similar methods.   
One area this training focuses on is enhancing communication and maintaining attention during a task. For example, one type of communication method focuses on highly structured hand-offs of information to avoid the loss of information, as might occur on a shift change or when transferring problemsolving to a coworker. Another method, called SBAR for Situation, Background, Assessment, and Recommendation, standardizes the description of a patient safety problem and the recommendations for resolving it (See Sidebar, XXX).   
Error prevention training also emphasizes leadership. Two of the behaviors commonly taught are starting all meetings with a patient safety story and using a praise-to-criticism ratio of 5:1. While considered leadership behaviors, everyone in an organization can benefit from practicing them.
The evidence for using more praise than criticism is modest and comes from the management literature (2, 3) as well as extrapolation from social science studies, especially studies of married couples, which reveal that the positive to negative ratio of comments in a marriage is a good predictor of marital longevity (4). Praise and criticism should be specific and focus on behavior that is related to patient safety. Examples of specific praise and criticism in a clinical laboratory are shown in Table 1. A laboratory leader who is unable to identify a sufficient number of specific examples for praise or criticism is probably not spending enough time in the lab.

Table 1. Examples  of specific praise and criticism related to patient safety

Specific Praise:

  • "Great catch in finding and correcting the BNP data entry error before the result was reported."
  • "I listened to the way you asked for read back on that potassium critical value, and I appreciate your attention to detail."
  • "I saw you implemented a no-interruption zone in the lab around the chemistry analyzer and I think that is a very good idea for reducing errors."

Specific Criticisms:

  • "You need to put some gloves on before handling that specimen."
  • "When you come in late, it leaves us short staffed and the turnaround time of troponin and other tests in the core lab suffers."
  • "Please do not answer the phone while you are pipetting that specimen."

It is important here to avoid generalities. General praise or criticism is not as effective, and often come off as thoughtless and insincere. For example, comments like, "you do a great job," or "your behavior is suboptimal," are not specific and don't show a direct relationship to patient safety.
A few other nuances to providing praise and criticism are worth noting. For example, praising someone in public for a specific patient safety behavior will reinforce the behavior in all who hear it. In contrast, criticism is best done in private. Finally, be sure not to interrupt a complex, error-prone task to provide feedback, as this increases the likelihood of error. Wait until the task is completed.
In summary, error prevention training encompasses a broad variety of methods, including structured communication, telling patient safety stories, and a 5:1 positive-to-negative feedback ratio about specific behaviors that effect patient safety. Healthcare institutions that can sustain error prevention training are constantly talking about patient safety and bringing problems to light. Just as important, they are demonstrating that patient safety is a paramount value and developing an obsession with patient safety likely keeps patients safer.


  • Brilli RJ, McClead RE Jr., Crandall WV, et al. A comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. J Pediatrics 2013;163:1638–45.
  • Zenger J, Folkman J. Harvard Business Review, Blog Network. The ideal praise-to-criticism ratio. (Accessed June 2014).
  • Losada M, Heaphy E. The role of positivity and connectivity in the performance of business teams: A nonlinear dynamics model. American Behavioral Scientist 2004;47:740–65.
  • Gottman JM. What predicts divorce: The relationship between marital processes and marital outcomes. New York: Lawrence Earlbaum, 1994.

How to Quickly Capture and Resolve Patient Safety Problems
One method used in error prevention training is called SBAR: Situation, Background, Assessment, and Recommendations. SBAR standardizes how the lab documents a patient safety problem and the recommendations for resolving it.

Example of an SBAR

Situation: Client complaint from Madison Hilltop Clinic due to missed specimen pickups by evening courier.

Background: Madison Hilltop Clinic  used to close at 7 p.m. and our courier usually picks up at 7:30 p.m. from the courier box so that we will have results for all specimens by 7 a.m. the next morning. When responding to this complaint, we discovered that Madison Hilltop Clinic is now staying open until 8:30 p.m., so a 7:30 p.m. pickup leaves specimens behind. This has led to prolonged turnaround time and specimen degradation. The clinic manager apologized for not notifying us of the change in clinic hours.

Assessment: To maintain our current level of service, specimens need to be picked up between 9 p.m. and 10 p.m. In addition, the lack of regular, structured communication with our client, Madison Hilltop Clinic, about clinic hours made us vulnerable to this type of error.


  • For a short-term countermeasure, use our commercial courier to do a last pickup between 9 and 10 p.m.
  • Long-term, we should adjust the routes of our own evening couriers. This will require running simulations and driving the new routes to make sure there are no unintended consequences of the new routes.
  • In our regular monthly communication with Madison Hilltop Clinic and other clients, we will add to our structured list of questions a question asking if there are any plans for changing clinic hours.

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