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February 2018 SEA-Q
Historically, the culture of health care has tolerated disruptive behavior exhibited by certain members in exchange for their high level of skills and expertise. However, many studies have shown that high quality and safe patient care depend on teamwork, communication and a collaborative work environment and culture. In 2009, the Joint Commission implemented a leadership standard that included a disruptive behavior policy. They defined disruptive behavior (or behaviors that undermine a culture of safety) as including "overt actions as verbal outbursts, and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities", and that disruptive behavior as well as failure in communication and teamwork are related to increased incidence of adverse event reports. 
A hierarchical culture can be useful in certain situations but these characteristics lead to significant difference in status and can lead to disruptive behavior. Also, in a centralized approach to management, team members are reluctant to challenge authority or speak up when errors are recognized. Hospital and surgical teams with rigid hierarchical culture have been shown to have inferior performance and safety climate measures.


  1. Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork Circulation 2013; 128:1139-1169
  2. Rosenstein AH. The Joint Commission disruptive behavior standard: intent and impact. J ASPR 2009; 16:6-7
  3. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anesth Scand 2009; 53:143-151

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