CommandGradientErrorinPre-HospitalCare This document discusses the concept of command gradient error and how differences in rank can inhibit communication and compromise patient care. It notes that perceived or actual differences in rank between healthcare providers can lead to a loss of shared understanding of the situation, or joint mental model, which could result in an undesirable event for the patient. It advocates for using graded assertiveness through the PACE model (Probe, Alert, Challenge, Emergency) to overcome rank differences and ensure patient safety remains the top priority.

3. CommandGradientError
inPre-HospitalCare
Neil Jeffers
London’s Air Ambulance
#smaccforce
2017

4. Descripti
on
The actual or perceived
difference in rank that inhibits
communication, leads to a loss in
Joint Mental Model which could
lead to an undesirable event

8. When Be
Recepti
ve
Leading

9. When Be
AssertiveFollowi
ng

11. Graded assertiveness -
PACE
Probe
Alert
Challenge
Emergenc
y
Is this right? Could we do this
better?
I am not sure that this is
right?
That’s not right! We need to
re-assess!STOP! I have
control

14. N.Jeffers@londonsairambulance.c
o.uk
@Capt_Dude
@LNDairamb

15. Achieving the National
Quality Forum's “Never
Events”
In most sentinel events, someone knew
something was wrong but either did not
speak up or spoke up but was ignored.
Prevention of Wrong Site, Wrong Procedure,
and Wrong Patient Operations
Robert K. Michaels, MD, MPH,* Martin A.
Makary, MD, MPH,† Yasser Dahab,
MD,* Frank J. Frassica, MD,‡ Eugenie
Heitmiller, MD,* Lisa C. Rowen, RN,
DNSc,§ Richard Crotreau, MD,¶ Henry Brem,
MD,∥ and Peter J. Pronovost, MD, PhD†

16. The effect of trans-cockpit
authority gradient on
Navy/Marine helicopter
mishaps.
Alkov RA1, Borowsky
MS, Williamson DW, Yacavone
DW.
Equal rank yielded lowest rate
Differing by 2 or more ranks –
highest rate