Tool: Two-Challenge Rule
The Two-Challenge Rule is another tool used to facilitate team members' speaking up. It was developed to manage conflict when team members’ perception of a situation differs. Human factor experts developed the rule to help airline captains prevent disasters when otherwise excellent decision makers experience momentary lapses in judgment.
In the clinical environment, team members should challenge colleagues if they have requested clarification but the response or confirmation does not ease the concern about potential harm to a patient. The Two-Challenge Rule can help team members frame communications about thoughts and reasoning about plans and decisions related to patient care. The goal is to create a teamwork culture where team members respectfully challenge one another when the plan is unclear or of concern.
Limiting the use of the Two-Challenge Rule to situations where the patient or another team member may be at high risk of harm is best. In teams where it is understood and supported, it can enable any team member to raise concerns about harms using a process others recognize and understand. When used appropriately, the Two-Challenge Rule can give all team members, including the patient or family, a vocabulary and process to best advocate for the patient’s needs.
The Two-Challenge Rule requires actions by both the person making the challenge and the person with whom they are raising the challenge.
If your initial assertion is ignored:
- It is your responsibility as the challenger to assertively voice your concern at least two times to ensure that it has been heard.
- If the outcome is still not acceptable:
- The challenger must take a stronger course of action.
The challenger should turn to the supervisor and move up the chain of command if necessary. This approach is intended to overcome our natural tendency to believe the team leader must always know what they are doing, even when the actions taken depart from established guidelines. When invoking this rule and moving up the chain, it is essential to communicate to the entire medical team that additional input has been solicited.
If you receive a challenge from another team member, it is your responsibility to acknowledge the concerns instead of ignoring the person. Any team member should be empowered to “stop the line” if they sense or discover an essential safety breach. This action should never be taken lightly but requires immediate cessation of the process to resolve the safety issue.
Both the Two-Challenge Rule and CUS (the following tool) are two-way interactions. It is equally important to behave appropriately if you are making or responding to the challenge. This interaction can set the tone for future interactions that might affect patient safety.
To further your understanding of the Two-Challenge Rule, consider the situation described below:
Mrs. Peters returned from the dentist after having a molar extracted. The nurse let Mrs. Peters’ aide, Judy, know that she should receive soft foods for a few days so as not to disturb the clot. Judy takes Mrs. Peters to dinner and watches the dietary aide deliver a regular meal. Judy stops the dietary aide, Matt, and tells him that Mrs. Peters needs a soft meal. Matt replies that Judy is wrong, as Mrs. Peters’ menu card says “regular diet.” Judy explains to Matt that, “No, Mrs. Peters just returned from the dentist, and the nurse said she needs soft foods.” Matt takes the tray back to talk to his supervisor.
- Was this an appropriate use of the Two-Challenge Rule?
- How should the dietary aide have responded?
As you reflect on the teams you are part of, try to recall whether you have ever used or observed the use of the Two-Challenge Rule. Can you think of times when using this rule could have prevented harm to a patient? How can you encourage greater use of this tool in the teams you are part of?
