Dr Mark Butler

Often in investigations of serious incidents a whole host of contributing factors come up. One which comes up time and time again is that someone had a vital piece of information or insight but didn’t feel able to share it with the team because they were intimidated by hierarchy, fear of confrontation or of being wrong.

Medicine does have a problem with this. Though paediatrics may have less of a rigid hierarchy than many specialities, it’s inevitable at some point – often in a stressful or time critical situation – that you’ll have to challenge another professional. It is vital to be able to do this constructively, professionally and with confidence. This has been referred to as ‘graded assertiveness’. The PACE acroynym is one way to help you structure this process. It was developed (predictably) in the aviation industry, but has been adapted in medicine. It stands for PROBE / ALERT / CHALLENGE / ESCALATE.  The precise form isn’t vital, but you should have thought a little on how you would handle this type of situation, and PACE can be a useful guide.

Here is a simple example of what you might say during an intubation, if you were unsure the ET tube was correctly placed –



Ask a question. “Are you sure that ET tube is in the trachea?”  you might follow this with further questions that highlight the reasons for your concern in a non-confrontational way – “Can you see the chest rising?”



Warn that you disagree with a particular action or assessment – “I don’t think that ET tube is in the trachea“. Again it could be helpful to add supporting information – “I can’t see the tube misting



Give evidence for your opinion and invite them to reassess or take alternative action “I don’t think that ET tube is in the trachea – the chest isn’t rising and the saturations are falling, we should take the tube out and bag again with a facemask



State the potential consequences of the mistake you believe is being made – “If you don’t take the ET tube out and start ventilating effectively, this child is going to become more hypoxic and may arrest” and escalate – “I’m calling the consultant


In almost all situations, ‘probe’ is enough. Good seniors will listen to you and respond constructively to questions (or have a good answer for them). As you become more senior, bear this in mind if someone is trying to tell you something!


Dr Mark Butler, Consultant Paediatrician, Evelina London Children’s Hospital


Further reading:

Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014 Feb 8;14:61.

Srivastava R. Speaking up–when doctors navigate medical hierarchy. N Engl J Med. 2013 Jan 24;368(4):302-5.

Life in the fast lane – Speaking Up

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