July 2011 Clinical Laboratory News: Disruptive Behavior

Disruptive Behavior
How Labs Can Recognize and Overcome Its Negative Effects

By Michael Astion, MD, PhD

In the laboratory, producing accurate and timely patient test results depends on teamwork, communication, and a collaborative work environment. However, laboratory staff who display intimidating and disruptive behaviors can quickly destabilize this cooperative environment and negatively impact patient safety. The Joint Commission advises health care organizations to confront behavior problems in order to promote a culture of safety and efficient team performance (1).

Verbal abuse negatively impacts patient safety.

To overcome the negative effects of disruptive employee behaviors, labs first need to recognize inappropriate conduct. The Joint Commission developed a list of workplace behaviors considered both disruptive and threatening to patient safety (1), including verbal abuse, physical threats, and intimidation, all of which can compromise laboratories’ ability to operate efficiently and effectively. Passive, uncooperative behavior, such as refusing to perform assigned tasks and not communicating with coworkers, also negatively affect laboratories’ day-to-day operations.

These disruptive behaviors are relatively common and have a significant impact on medical errors, according to oncology nurse and author, Theresa Brown. In a recent New York Times article, she explained how such inappropriate workplace conduct adversely affects patient safety (2). For example, out of fear, a nurse being bullied by a doctor would be less likely to question the doctor’s orders, despite suspecting an error. Brown contended that a healthcare worker being abused or intimated by a co-worker often avoids communicating with the perpetrator, thereby increasing the probability of a medical error. In addition, she observed that any type of disruptive behavior negatively affects patient safety because it distracts and upsets the people involved. When staff members are not able to concentrate on their assigned tasks, they are more likely to commit noncognitive errors, meaning they make mistakes in a process that is normally automatic.

Examples of Disruptive Behavior
Disruptive Behavior
Potential Effect on Patient Safety
Physical and verbal intimidation of a coworker, leading to decreased communication. Perpetrator makes a harmful lab error because victim, who suspects the error, refuses to speak up.
Refusal to communicate with coworkers regarding a problem testing situation in the lab, such as an intermittent problem with lab reagents or instruments. Problem goes unresolved, leading to erroneous results, delays, and patient harm.
Refusal to perform a laboratory task, such as processing a specimen or performing a laboratory test. Delay in testing that harms patient.
Refusal to make an outgoing phone call or answer an incoming phone call related to patient care. Critical/urgent test results not communicated to care provider in timely fashion leading to patient harm.
Refusal to come to work despite being on-call. Lab understaffing leads to delays in testing.

Bad Behavior Leads to Lab Errors

How serious is the disruptive behavior problem in healthcare systems today? Rosenstein and O’Daniel recently described the scope of the problem based on a survey involving more than 100 Veteran’s Health Administration Hospitals (3). In their study, approximately 4,500 physicians, nurses, and other healthcare workers responded to questions about the frequency of disruptive behavior and its effect on patient safety. More than three-quarters of participants reported witnessing disruptive behavior by physicians, while two-thirds had observed disruptive behavior by nurses. Furthermore, 71% said they believed there is a link between disruptive behaviors and medical errors, and 18% indicated that they were aware of specific adverse events related to disruptive behavior.

Policies and Procedures

Given the possible dire consequences of medical errors, clinical laboratories should not hesitate to take action against employees who display disruptive behaviors (See Table, above). The first step is to develop and enforce policies and procedures based on a professional code of conduct (4). These policies and procedures must include a protocol for reporting and managing disruptive behavior without fear of retaliation. A successful workplace environment depends on encouraging lab workers to confront these behaviors at all levels of the organization. Removing intimidators and disruptors from the laboratory not only boosts productivity but also helps ensure patient safety.


  1. Behaviors that undermine a culture of safety. The Joint Commission Sentinel Event Alert. Issue 40. July 9, 2008. Available at: www.jointcommission.org/assets/1/18/SEA_40.PDF, accessed May 26, 2011.
  2. Brown T. Physician, Heel Thyself. New York Times. May 7, 2011. Available at: www.nytimes.com/2011/05/08/, accessed May 26, 2011.
  3. Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008:34;464–71.
  4. Saxton RS, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: A review of the literature. J Patient Saf 2009;5:180–183.
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Patient Safety Focus Editorial Board

Michael Astion, MD, PhD
Seattle Children's Hospital
Seattle, Washington

Peggy A. Ahlin, BS, MT(ASCP)
Salt Lake City, Utah 

Corinne Fantz, PhD
Emory University
Atlanta, Georgia

James S. Hernandez, MD, MS
 Mayo Clinic Arizona
Scottsdale and Phoenix

Brian R. Jackson
ARUP Laboratories
Salt Lake City, Utah

Sponsored by ARUP Laboratories, Inc.