Speak Up for Patient Safety
Tools for Advocacy and Assertion:
CUS When It’s Critical!
© Linda Mueller, LMHS – for internal use only
INTRODUCTION
SAY: Just like healthcare, car manufacturing is/was a 24/7 operation. Prior to
1988, it had been a hard and fast rule in automotive plants that an assembly line
must never stop.
ASK: What was the result of never stopping the auto assembly line?
NOTE: Get volunteers to answer. You should hear things like: waste, defects,
rework, injuries, over-production, etc.
SAY: When Toyota first told its employees they could stop the line when trouble
developed, they couldn’t believe it! In just a few short weeks, however, Toyota
found that safety and quality had significantly improved.
ASK: In healthcare, when should we “stop the line?”
NOTE: Get volunteers to answer. You should hear things like: when patient safety
is at risk, etc.
SAY: Whenever we are faced with a critical situation and we notice or sense that
something is wrong, it is our duty to “stop the line.” The tool to use is CUS.
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Speak Up for Patient Safety
Please Use CUS Words
but only when appropriate!
© Linda Mueller, LMHS – for internal use only
SAY:
We’re going to learn a tool to help empower us to “stop the line.” It is called CUS. CUS is a “verbal alarm”
that, when the words are spoken, will help all team members to clearly understand not only the ISSUE, but
also the magnitude or severity of the issue.
CUS is a patient safety technique developed by the Agency for Healthcare Research and Quality (AHRQ).
Here are the CUS steps:
First, state your concern.
Second, state why you are uncomfortable.
Third, state that this is a safety issue, identify how it’s a safety issue, and then state what action you want
taken.
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Speak Up for Patient Safety
How Do We Know
it’s a safety issue?
© Linda Mueller, LMHS – for internal use only
ASK: But how do we know if this is a safety issue?
NOTE: Refer to the “Is This a Safety Issue? Red Flags” handout. Go over each item. Ask people to
work in groups of 3 for 5 minutes and to give actual workplace examples for each Red Flag item. For
example with ambiguity—’when there is a lack of clarity of who is responsible for something’.
Get volunteers to suggest examples.
SAY: The CUS technique will help with each of these.
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Speak Up for Patient Safety
CUS Demonstration 1
© Linda Mueller, LMHS – for internal use only
SAY: Let’s hear how the CUS technique would work in this little Demonstration Scenario. I have
parts for 3 people to read: the narrator, Nurse Amy, and Nurse Kim. (Get volunteers to read.)
NARRATOR: Danny Jones is a 4 year old patient with a history of juvenile diabetes who
is seen in the Pediatric Unit following a recent episode. Although the labs show his
blood sugar is nearly under control, he is being held for observation until his vitals are all
normal. It is a very busy day on the unit and time for his insulin. Nurse Kim is quickly
preparing the injection...until the following conversation with Nurse Amy takes place.
AMY: Kim, the injection you are preparing seems to be awfully large and the vial is a
different color than the patient’s previous injections. How much insulin are you preparing
to give Danny Jones?
KIM:
5 cc’s.
AMY:
I’m concerned that we may be giving him too much insulin.
KIM:
Why is that?
AMY: Well, we usually give adult diabetics 0.5 cc’s of insulin. I am uncomfortable
because he is a child and is so much smaller than an adult.
KIM:
Look, Amy, I’ve got to hurry and get this done, but you could be right. I’m
new to the Pediatric Unit and not that familiar with working with children.
AMY:
This is a safety issue and I really need you to stop what you’re doing and
double check the orders more closely.
NARRATOR: Kim put down the syringe and hurried over to consult the chart again,
while Amy looked for the appropriate vial. They both want what’s best for Danny Jones
and will monitor the situation more carefully.
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Speak Up for Patient Safety
© Linda Mueller, LMHS – for internal use only
ASK: Did they follow the CUS technique steps? (Go through each one.)
First, state your concern.
Second, state why you are uncomfortable.
Third, state that this is a safety issue, identify HOW it’s a safety issue, and then state what action you
want taken.
ASK:
First, is this a real safety issue? What led Amy to believe it was?
Second, refer to your list of Red Flag Safety Issues. What was Nurse Amy’s Red Flag? (It could be one
or more Red Flags.)
Third, what do you think would have been the outcome of this situation if Nurse Amy had not used the
CUS technique?
SAY: This is in fact a real situation that actually happened here. Nurse Amy prevented the death of a
little boy because she took it upon herself to “stop the line.”
ASK: Has there ever been a time that YOU know of – when someone has had to “stop the line?”
NOTE: Get volunteers to share.
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Speak Up for Patient Safety
What if…
© Linda Mueller, LMHS – for internal use only
ASK: If the safety issue is NOT resolved, what should you do?
•Notify a supervisor
•Follow the chain of command
•Take action yourself to protect the patient or person in danger
The third step empowers you to “Stop the Line” when your patient’s safety is at stake. That might mean
getting the help of a supervisor or house supervisor, or the house medical staff person on duty. It means
doing whatever you have to do to assure your patient is safe.
NOTE: In some emergency situations, you may not have time to follow ALL the CUS steps. In that case,
go directly to Step 3, say what you need to happen right now.
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Speak Up for Patient Safety
A CUS Demonstration 2
© Linda Mueller, LMHS – for internal use only
SAY: NOW let’s see what happens in another scenario. (Give parts to 3 people to read.)
NARRATOR: Ed Johnson is a 41 year old patient with a history of hypertension who is
seen in the Cardiology Clinic for follow-up after his recent heart attack. An EKG shows
no evidence of changes, although his blood pressure is a little high. All of his other vitals
are normal, so Dr. Ross is preparing to discharge Ed to home, as Ed requested...until
the following conversation with Nurse Tracy takes place.
TRACY: Dr. Ross, Ed Johnson is complaining about a tightness in his chest. He
appears to be in some pain. We still don’t have the test results back for his cardiac
enzymes. I’m concerned that we may be discharging him too soon.
DR.ROSS: I hear you. His blood pressure IS 170 over 110, but his EKG shows no
ischemic changes.
TRACY: I’m uncomfortable discharging him until we know for certain that the Troponin I
level is normal. It should be called in to us soon.
DR. ROSS: I understand. We could always discharge him with instructions to call the
office the next day if he’s having problems.
TRACY: Dr. Ross, I am concerned that Ed might be in the onset of another heart attack,
since he’s having pain and his blood pressure is elevated. I am uncomfortable with
releasing him because he lives alone and it would be unsafe for him if his pain got
worse. I really need you to attend to Ed and monitor the situation more closely.
DR. ROSS: You could be right, Tracy. Let’s get him hooked up right away.
TRACY: Thanks, Doctor. We’d both feel terrible if something happened that we could
have prevented.
NARRATOR: Dr. Ross hurried in to see Ed Johnson again and explained the situation to
him while Tracy applied the patches for the EKG. They both monitored the situation
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Speak Up for Patient Safety
Another “What If”
© Linda Mueller, LMHS – for internal use only
ASK: Did they follow the CUS steps? (Yes.)
What do you think might be the outcome of this situation? (Greater safety for the patient.)
SAY: Because we live in the real world, we need to consider the following question:
What if Dr. Ross isn’t cooperative? What if he says, “I’M the doctor and Ed Johnson is
MY patient. How many years of med school have YOU had? I make the calls for MY patient.”
What should you do? (Get help from a supervisor, follow chain of command, or stop him
yourself)
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Speak Up for Patient Safety
Tips for a Successful CUS:
1. Focus on the common goal – safe, high quality
patient care
2. Depersonalize the discussion – it’s not about
you and me– it’s about the patient.
3. Avoid judgment: who’s right, who’s wrong
4. Focus on what needs to happen for us to do the
right thing for the patient?
© Linda Mueller, LMHS – for internal use only
SAY: Here are some tips to help us be successful using the CUS technique.
NOTE: Go over each point.
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Speak Up for Patient Safety
Now…let’s practice:
© Linda Mueller, LMHS – for internal use only
SAY: Now we’re going to practice using CUS ourselves. We’re going to work with a partner and take 5
minutes to complete. First, we’ll complete the case study handout, and then we’ll take turns practicing first one person will practice CUS, then the other will CUS. You can use the handout, Tips for a
Successful CUS, to help you.
NOTE: Refer to the Case Study handout and the Tips for a Successful CUS slide.
ASK for volunteers to demonstrate the CUS technique.
Offer feedback on what they did well or other things to consider.
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Speak Up for Patient Safety
Debriefing CUS
Every CUS situation requires a review:
• An opportunity for individual, team, and
organizational learning
• The more specific the review, the better
• What did we do well?
• What did we learn?
• What would we do differently next time?
© Linda Mueller, LMHS – for internal use only
PROCESSING:
ASK: Did you include all the steps? Explain why you feel uncomfortable? Tell HOW it’s a safety issue? Assert what
you need right now?
SAY: “Because the CUS technique is to be used in critical situations, it is necessary for the team to conduct a CUS
review EVERY time we use it. Done properly, the review can be a great opportunity for individual, team, and
organizational learning.
First, we want to be positive and NOT punitive. Our goal is to learn, not judge or blame – and to insure that what’s
broken gets fixed and never happens again!
Second, we’ll need the specifics of the situation. It’s important that the information be as accurate as possible.
(Pretend that you are a reporter for 60 Minutes – how would a neutral reporter see it?)
Third, the review will be conducted as soon as possible after using the CUS technique. The most effective reviews
take place within 24 hours so that the situation is still present and important in our memory.
Fourth, at the review, everyone will speak, starting with the most junior folks. The discussion will be focused and crisp
and to the point. We will ask the questions in the last 3 bullet points. Again, the goal will be to learn so we can
improve or resolve the issue that created the situation in the first place.
SAY: “Even if the CUS that was called turned out to be a “false alarm”, we want to still have the review and learn from
the experience---- and again, it should never be punitive or negative. It’s better to have CUSSED and had it turn out
to be nothing than to have not “cussed” when we needed to.”
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Speak Up for Patient Safety
Tools for Advocacy and Assertion:
The CUS Technique
Closing Exercise:
• Dear Patient Letter
© Linda Mueller, LMHS – for internal use only
ASK: Do you think you’ll be able to use the CUS technique when you’re working on the floor? It might be
uncomfortable until we get used to doing it, but it gets easier with practice. Our entire team will benefit and we’ll take
better care of our patients.
SAY: Now that we’re at the end of our session, I’d like you to take a moment to complete the Dear Patient Letter.
Think for a moment about how you’ll use the technique you just learned, and what you’d like to say to your patient.
Let’s take 5 minutes to do that.
ASK: How can you use this Dear Patient Letter? What ideas do you have? (Have volunteers answer.)
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Speak Up for Patient Safety
The CUS Technique
Evaluations, please:
•
•
•
•
All feedback is positive
What went well
What should be changed next time
Suggestions for making the course better
© Linda Mueller, LMHS – for internal use only
Wrap Up:
SAY:
Please fill out the evaluation sheet. Your written comments are especially appreciated to
let me know if this information is helpful to you. Remember that all feedback is positive,
and be sure to include your ideas for making the course better.
NOTE: Thank participants for their participation.
Collect sign-in sheet and evaluations and return to Denise Sentner, Leadership Development.
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