ISMP: Be Wary of ‘Misspeakers’ Who ‘Shoot from the Hip’

By the Institute for Safe Medication Practices

Have you ever been tempted to answer a question even though you were not sure of the answer? Perhaps the fear of looking stupid was so overwhelming that any answer was thought to be better than no answer. Under pressure, we may “shoot from the hip,” forming an answer to a question in seconds and not taking time to weigh options or consider the question. The first answer that springs to mind becomes the only answer, and if it’s wrong—which it often is—we “misspeak.” But, speaking off the cuff with authority when you are not certain of the answer is a prescription for disaster in healthcare.

Recently, a patient encountered several instances of “misspeaking” by healthcare workers who felt a need to say something authoritative, despite their apparent lack of knowledge on the issue. The patient had just undergone a root canal. Her dentist had prescribed amoxicillin to prevent an infection. However, the patient had a documented allergy to penicillin, which was listed in her dental record. When the patient received the handwritten prescription, she asked the dentist’s receptionist if it was safe to take amoxicillin given her penicillin allergy. The receptionist assured the patient that the dentist must have verified the prescription. When the patient dropped off the prescription to be filled at the pharmacy, she asked the pharmacy technician to verify that the medication ordered was not penicillin since she was allergic to penicillin. The technician quickly replied, saying, “No, it’s not. That’s why your doctor prescribed it.” Trusting the dentist office and pharmacy staff, she took the medication. Several days later, she began to notice a rash that extended over her entire body, which was diagnosed as an allergic reaction to the amoxicillin. She was fortunate that her allergic response did not lead to an anaphylactic reaction.

Why People “Shoot from the Hip” and “Misspeak”

Overconfidence effect. People who “shoot from the hip” and “misspeak” may experience a cognitive bias known as the overconfidence effect. This bias leads to an excessive confidence in one’s own answers to questions (Hoffrage, 2004). This bias is self-serving and reflects our natural desire to be perceived as knowledgeable. Studies show that confidence often exceeds accuracy, particularly when answering difficult questions about an unfamiliar topic (Hoffrage, 2004; Alpert & Raiffa, 1982; Harvey, 1997). Even when warned about the bias, people still tend to be overconfident (Alpert & Raiffa, 1982). They believe in the accuracy of their answers based on how easily the idea sprang to mind (availability heuristic), and they tend to cling to their initial assumptions (anchoring heuristic) and silence any thoughts that suggest pursuing alternative answers (premature closure). The overconfidence effect has been called the most “pervasive and potentially catastrophic” of all the cognitive biases to which we fall victim (Plous, 1993).

Dunning-Kruger effect. People who “shoot from the hip” and “misspeak” may fail to realize they are providing incompetent answers when they venture outside their areas of expertise because they lack the skill to distinguish between competence and incompetence. Known as the Dunning-Kruger effect, incompetent people who “misspeak” not only reach erroneous conclusions and make unfortunate choices, but their incompetence robs them of the ability to realize it (Kruger & Dunning, 1999). People are most often confident in situations in which they are most ignorant—they know just enough to make them dangerous (Pacific Standard, 2014).

Reluctance to say, “I don’t know.” While the overconfidence effect and Dunning-Kruger effect contribute to answering a question confidently but inaccurately, people also have a tendency to answer questions knowing full well that their answer may not be accurate. While some may argue that “I love you” are the three hardest words to say, Levitt and Dubner, the authors of Freakonomics (2005) and Think Like a Freak (2014), suggest that “I don’t know” is even harder to say.

In healthcare, there’s a general view that it’s your job to be an expert in your field, so the expectation of knowledge is great. Look at our medical training programs, for example. Attending physicians ask residents questions, and residents ask interns questions, down the line to medical students during training. But the resident, intern, and student quickly learn that saying “I don’t know” is viewed poorly by their superiors. We teach healthcare professionals that it’s never a good idea to admit you don’t know something, particularly if there’s an expectation that you should know it. We tacitly teach healthcare professionals that, no matter what, they should provide an answer and hope for the best. 

In a study by Waterman, Blades, and Spencer (2001), a majority of children and more than 20% of adults provided answers to wholly unanswerable questions about two short stories they were told. All performed very well when asked questions that could be answered based on the stories. But at least 20% of adults and most of the children were unwilling to say “I don’t know” when asked questions for which the answers were never provided in the stories. Responses to unanswerable questions were highest with closed-ended questions requiring just a yes or no response. However, the impulse to provide answers to questions despite uncertainty is also high when dealing with complex processes or cause and effect relationships (Levitt & Dubner, 2014).

It is easy to ridicule anyone who fakes knowing the answer, but it’s also easy to understand their motivation—everyone likes to look smart and feel like they belong. The reluctance to say “I don’t know” stems from how the person answering a question perceives the expectations of the person to whom the answer is owed (Levitt & Debner, 2014). Admitting that you don’t know the answer is often too deprecating. People also fear that saying “I don’t know” will be viewed as laziness or unwillingness on their part to find the answer. 

Expectations of timeliness. Healthcare staff members are often pressured to provide an answer immediately when a question is asked, and with busy schedules, they may be only too happy to oblige. For pharmacists, managing dispensing time expectations while juggling new orders and order clarifications may contribute to the pressure to answer questions without due contemplation. Prescribers may be pressured to manage high patient volumes and wait times. Nurses may be multitasking to provide care for multiple patients in a fast-moving, ever-changing healthcare setting. This pressure and expectation from others for instantaneous responses to their questions may lead to “misspeaking.”

Placating patients. Answering questions can take time. Thus, healthcare practitioners may “shoot from the hip” and “misspeak” when trying to quickly answer a patient’s question because they simply need to move forward with their work. This may involve the provision of misinformation, such as a pharmacist telling a patient who questions the appearance of a medication that it is just a different generic product, without taking the time to verify that it isn’t the wrong drug; or, answering a question that may have some truth to it but not enough details to really answer the question.

Safe Practice Recommendations

“Shooting from the hip” sometimes hits the target, but it is seldom precise and often leads to “misspeaking.” To reduce these behaviors, consider the following.

Supportive culture. Build a culture in which all staff, regardless of rank, experience, or training, feel safe and supported when acknowledging that they don’t know the answer to a question. Responsibility for giving staff permission to say “I don’t know” belongs with leaders and mentors who should recognize that, in a learning organization, the first step to learning is knowing there are things you don’t know, and things you don’t even know you don’t know (Morris, 2010). In highly reliable organizations with excellent safety records, there is a perpetual uneasiness with the “unknown unknowns,” which leads to a deference to expertise (Weick, Sutcliffe, & Obstfeld, 1999). Questions that require specialized knowledge are only answered by those with the requisite expertise because all are encouraged to say, “I don’t know,” when appropriate and to seek out those who would know the answers. There is little pressure to answer questions quickly; staff have a preoccupation with failure that helps them recognize the risks associated with “shooting from the hip.” In healthcare, we must also avoid rushing people for answers and allow the time necessary to seek out the correct answers whenever possible.

Group discussions, simulations, and role playing. To reduce the risk of off-the-cuff answers to questions in the absence of expertise, provide training that helps staff calibrate their assessment of whether they should answer a question, seek out the answer and then provide it, or defer to expertise. Evaluate the environment of care and identify particular circumstances under which staff may be more likely to answer questions without confirmation of the answers. Use these circumstances to address the issue during training programs using group discussions, simulations, and role-playing. Clearly delineate what types of questions non-clinicians can answer and those that must be referred to a clinician, and teach all staff ways to seek out the answers to questions without embarrassment or fear of punishment. Remind staff that the lack of accurate and thoughtful answers to questions is likely to produce consequences that are much worse than the embarrassment of not knowing the answer. 

Teaching style. Enhance awareness among healthcare program faculty, leadership, and management about the impact their teaching or management style may have on staff behavior. They should serve as role models and demonstrate that staff should not be afraid to admit that they do not know the answer to all questions. Instead, teaching moments should come from allowing staff and students to explore the most accurate answers to questions from experts.

Engage patients. Encourage patients to take an active role in their healthcare and persistently ask questions if they are not satisfied with the answers they receive.

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This column was prepared by the Institute for Safe Medication Practices (ISMP), an independent, nonprofit charitable organization dedicated entirely to medication error prevention and safe medication use. Any reports described in this column were received through the ISMP Medication Errors Reporting Program. Errors, close calls, or hazardous conditions may be reported online at www.ismp.org or by calling 800-FAIL-SAFE (800-324-5723). ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for patient safety data and error reports it receives. Visit www.ismp.org for more information on ISMP’s medication safety newsletters and other risk reduction tools. This article appeared originally in the September 11, 2014 issue of the ISMP Medication Safety Alert!

References

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Harvey, N. (1997). Confidence in judgment. Trends in Cognitive Sciences, 1(2), 78–82.

Hoffrage, U. (2004). Overconfidence. In P. Rüdiger (Ed.), Cognitive illusions: A handbook on fallacies and biases in thinking, judgement and memory (pp. 235–254). Hove, UK: Psychology Press.

Kruger, J. & Dunning D. (1999). Unskilled and unaware of it: How difficulties of recognizing one’s own incompetence lead to inflated self-assessments. Journal of Personality and Social Psychology, 77(6), 1121–1134.

Levitt, S.D. & Dubner, S. J. (2005). Freakonomics. New York: William Morrow.

Levitt, S.D. & Dubner, S. J. (2014). The three hardest words in the English language. In S. D. Levitt & S. J. Dubner. Think like a freak (pp. 19–48). New York: HarperCollins.

Morris, E. (2010, June 20). The anosognosic’s dilemma: Something’s wrong but you’ll never know what it is (part 1). The New York Times. Retrieved from www.ismp.org/sc?id=410

Pacific Standard. (2014, January 23). Why people have so much trouble recognizing their own incompetence. Retrieved from www.ismp.org/sc?id=409

Plous, S. (1993). The psychology of judgment and decision making. New York: McGraw-Hill.

Waterman, A. H., Blades, M., & Spencer, C. P. (2001). Interviewing children and adults: The effect of question format on the tendency to speculate. Applied Cognitive Psychology, 15(5), 521–531.

Weick, K. E., Sutcliffe, K. M., & Obstfeld, D. (1999). Organizing for high reliability: Processes of collective mindfulness. Research in Organizational Behavior, 21, 81–123.