Speaking Up for Safety
Using graded assertiveness (PACE) to raise patient-safety concerns.
By the end of this module you will be able to
- Apply the steps of the PACE framework to raise patient safety concerns.
- Choose appropriate PACE responses across six realistic scenarios.
- Use a structured approach to escalate concerns that are dismissed.
AI statement: Claude.ai was used to reformat a facilitator-led workshop lesson into this eLearning package. All images were created with ChatGPT and all audio files were created with ElevenLabs. The module has been critically reviewed for clinical accuracy.
Why speaking up matters
Have you ever noticed something concerning at work, and found it hard to say so?
Maybe the person was senior to you. Maybe you weren't certain you were right. Maybe you didn't want to make things awkward. If so, you're in good company: most clinicians have been there.
Failure to speak up is repeatedly identified as a contributing factor in serious clinical incidents.
Why do capable clinicians stay quiet?
Tap each card to hear the inner voice behind it.
The good news: speaking up is a learnable skill. Graded assertiveness is a proven method for improving speak-up behaviour in clinicians. It starts with gentle curiosity and becomes more assertive only as patient risk increases, which protects patients and working relationships. Speak-up training has also been shown to improve clinician confidence and wellbeing.
"By fostering environments that support open communication, organisations can enhance patient safety and quality of care."
The PACE framework
PACE is a graded assertiveness framework that helps you raise concerns for patient safety. You start low, with a question, and only escalate if the concern isn't resolved or the risk increases.
Select each letter, starting with P, to reveal that step of the framework.
Probe · Ask a question to clarify
Sentence stems: "Do you see that…?" · "Did you mean to…?" · "Did you realise that…?"
Example: "Do you know if this patient has any allergies?"
Select P to reveal the first step.
Alert · State your concern clearly
Sentence stems: "I'm worried that…" · "I think that…"
Example: "I think this patient has a penicillin allergy."
Select A to reveal the second step.
Challenge · Contest the current action to protect safety
Sentence stems: "Please don't…" · "We should not…"
Example: "Please don't give the amoxicillin."
Select C to reveal the third step.
Emergency · Prevent the action and escalate
Sentence stem: "STOP! Do not…"
Example: "STOP! Don't give the amoxicillin."
Select E to reveal the fourth step.
The same conversation at three levels of assertiveness: question, challenge, stop.
Start at Probe whenever you can. It's the easiest to say and usually resolves the issue. But if the patient is at immediate risk, it's appropriate to jump straight to Challenge or Emergency.
Quick check Practice · ungraded
A colleague is about to administer a medication and you think, but aren't sure, that the dose looks high. Which PACE level fits best as your opening move?
Practice scenarios
You're about to work through six realistic moments from across the patient journey, from admission to follow-up. In each one, something isn't right, someone has already waved it away, and you're not completely certain.
That uncertainty is the point: PACE is designed for it. Remember, probing with a question is always a safe first move.
Registration and admission
During admission, an elderly patient mentions they think they are "here for the scan", but the consent form and booking list say they are admitted for a minor surgical procedure. The staff member handing over the paperwork says, "It's all correct, just get them settled." It is not clear whether the patient understands what is about to happen.
NSQHS alignment: Actions 2.2, 2.5 (correct identification and procedure matching); 6.5, 6.6 (informed consent).
How would you respond? Draft one sentence for each PACE level: Probe, Alert, Challenge, Emergency. Aim to maintain the relationship.
Read each one, and press play to hear how it sounds out loud.
"Can I just check: does the patient understand they're booked for a procedure today, not a scan?"
"I'm concerned this patient thinks they're here for a scan. I don't think their consent is informed."
"Please don't progress them for the procedure until consent has been re-confirmed with the patient."
"STOP! Do not proceed. The patient does not understand what is about to happen."
Your wording can differ. What matters is matching assertiveness to the level of risk.
In this situation, which PACE level would you open with?
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Planning care and providing treatment
A patient with a known allergy has been prescribed a medication that appears to fall into the same drug class. The person who charted it is already moving on to the next patient, clearly under time pressure. You have a strong sense that something is wrong, but you are not certain about the cross-reactivity of the drug.
NSQHS alignment: Actions 4.11 (medication information and risk); 5.13 (comprehensive care plan); 2.6, 2.7 (shared decision-making).
How would you respond? Draft one sentence for each PACE level: Probe, Alert, Challenge, Emergency. Aim to maintain the relationship.
Read each one, and press play to hear how it sounds out loud.
"Isn't this in the same class as the drug they're allergic to? Can we double-check?"
"I'm worried this medication could cross-react with the patient's documented allergy."
"Please don't administer it until pharmacy has confirmed it's safe for this patient."
"STOP! Do not give that medication. This patient has a documented allergy."
Your wording can differ. What matters is matching assertiveness to the level of risk.
In this situation, which PACE level would you open with?
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Acute deterioration and escalating care
A patient's observations have drifted into the escalation zone on the track-and-trigger chart over the last hour. The family is worried and has said so twice. Someone reviews the chart and says, "They always run like that, let's review them in the next round." You are concerned that the patient is genuinely deteriorating and that waiting is not safe.
NSQHS alignment: Actions 8.5, 8.6, 8.8, 8.9 (recognising and responding to acute deterioration); 8.7 (escalation by patients and families).
How would you respond? Draft one sentence for each PACE level: Probe, Alert, Challenge, Emergency. Aim to maintain the relationship.
Read each one, and press play to hear how it sounds out loud.
"Have you seen that the obs have been trending into the escalation zone for the past hour?"
"I'm worried this patient is genuinely deteriorating. The trend is worsening and the family has raised concerns twice."
"We should not wait for the next round. This patient needs a review now."
"STOP! I'm activating the rapid response call. This patient meets escalation criteria."
Your wording can differ. What matters is matching assertiveness to the level of risk.
In this situation, which PACE level would you open with?
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Transitions of care
A patient is being transferred between units. The handover is rushed, the medication list does not match what is documented in the notes, and the person handing over is already leaving, saying "It's all in the system, you'll be fine." Accountability for the patient is being passed across without a clear patient picture.
NSQHS alignment: Actions 6.7, 6.8 (structured clinical handover); 4.6, 4.12 (medication reconciliation and medicines list at transitions).
How would you respond? Draft one sentence for each PACE level: Probe, Alert, Challenge, Emergency. Aim to maintain the relationship.
Read each one, and press play to hear how it sounds out loud.
"Before you go, did you realise the medication list doesn't match what's in the notes?"
"I'm concerned we don't have an accurate picture of this patient's medications."
"Please don't leave until we've reconciled the medication list together."
"STOP! I can't safely accept this handover with an unresolved discrepancy. I'm escalating to the shift coordinator now."
Your wording can differ. What matters is matching assertiveness to the level of risk.
In this situation, which PACE level would you open with?
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Discharge home
A patient is being discharged today and there is pressure to free up the bed. The discharge summary does not include a recent change to their anticoagulant, and the patient seems unclear about what to take at home. Someone says the GP can sort out the details. There is a worry that the patient will go home and take the wrong dose.
NSQHS alignment: Actions 6.5, 6.6 (identification and matching); 5.13 (alignment with care plan); 4.12 (medicines list to receiving clinicians).
How would you respond? Draft one sentence for each PACE level: Probe, Alert, Challenge, Emergency. Aim to maintain the relationship.
Read each one, and press play to hear how it sounds out loud.
"Did you realise the discharge summary doesn't include the recent anticoagulant change?"
"I'm worried this patient will go home and take the wrong dose."
"We should not discharge them until the summary is corrected and the patient understands their medications."
"STOP! Do not discharge this patient yet. The anticoagulation plan isn't safe to send home as it stands."
Your wording can differ. What matters is matching assertiveness to the level of risk.
In this situation, which PACE level would you open with?
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Follow-up communication
A patient was discharged a week ago with an urgent outpatient referral and a safety plan after presenting with thoughts of self-harm. It emerges that the referral was never actioned and no follow-up call has been made. Someone says, "It's the patient's responsibility to chase it up now they're discharged." This is a critical gap that should be addressed immediately.
NSQHS alignment: Actions 6.9 (communicating critical information); 6.8 (transferring responsibility and accountability); 5.31, 5.32 (predicting, preventing and managing self-harm).
How would you respond? Draft one sentence for each PACE level: Probe, Alert, Challenge, Emergency. Aim to maintain the relationship.
Read each one, and press play to hear how it sounds out loud.
"Has anyone confirmed whether the urgent referral was actually actioned?"
"I'm concerned this patient has a safety plan but no follow-up has happened for a week."
"We can't leave this to the patient to chase. The referral needs to be actioned today."
"This is urgent. I'm escalating to the team leader now so the patient is contacted immediately."
Your wording can differ. What matters is matching assertiveness to the level of risk.
In this situation, which PACE level would you open with?
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What did you notice?
- Where did you naturally want to start, and what does that tell you?
- Would you have said something different if you were the most junior person in the room? The most senior?
- Some scenarios involved genuine safety risk. Did you spot which ones, and how did that change where you started?
- What would make it easier for you, or your team, to feel safe speaking up?
Escalation
Sometimes you'll do everything right and still be waved away. "They always run like that." "It's all in the system." "The GP can sort it out." Being dismissed is not the end of your responsibility. If you still believe the patient is at risk, the next step is to escalate.
Select each number, starting with 1, to reveal what to do next.
Move one level up
If your Probe was brushed off, move to Alert. Make the concern explicit: "I'm worried that…"
Select 1 to reveal the first step.
Use your local escalation pathway
Every service has one: team leader, shift coordinator, after-hours manager, rapid response system. Escalating past the person who dismissed you is not going over their head; it's following the system that exists for exactly this moment.
Select 2 to reveal the second step.
Document and close the loop
Record your concern and the response. Follow up to confirm the risk was addressed.
Select 3 to reveal the third step.
Before you finish this lesson: can you name your local escalation pathway right now? Who would you call, in what order, on your next shift? If not, find out today and write it on your PACE card.
Patients and families can escalate too. Under NSQHS Action 8.7, health services must support escalation of care by patients, carers and families. Family concern is a legitimate trigger, not an inconvenience.
Assessment
This knowledge check has 4 questions. You must answer all 4 correctly to pass. If you don't pass, review the PACE framework and try again. You have unlimited attempts.
Question 1 · You notice something that doesn't look right, but you're not certain there's a problem. What is usually the best first step?
Question 2 · Match each statement to its PACE level.
Question 3 · When is it appropriate to skip straight to Challenge or Emergency?
Question 4 · You raise a concern at Alert level. It is dismissed, but you're still concerned. What three actions can you use to escalate?
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What is one thing you'll do differently the next time you see something concerning?
Speaking up protects patients. It also protects you and your colleagues from carrying the weight of things left unsaid. Start with a question. Escalate with the risk. And keep your PACE card close.
Key takeaways
Silence is a predictable response to hierarchy, uncertainty and relationship pressure. PACE gives you a way through it: start low, with a question, and escalate only as the risk requires.
The PACE framework
Remember
- Start at Probe whenever you can; it usually resolves the issue. If the patient is at immediate risk, jump straight to Challenge or Emergency.
- You don't need to be certain to speak up. Uncertainty is exactly what a Probe question is for.
- If you're dismissed and risk remains: restate one level up, use your local escalation pathway, then document and close the loop.
- Family concern is a legitimate escalation trigger, not an inconvenience.
Module feedback
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Bibliography
- Hanson, J., Walsh, S., Mason, M., Wadsworth, D., & Framp, A. (2020). 'Speaking up for safety': A graded assertiveness intervention for first year nursing students in preparation for clinical placement: Thematic analysis. Nurse Education Today, 84, Article 104252. https://doi.org/10.1016/j.nedt.2019.104252
- Lee, E., De Gagne, J. C., Randall, P. S., Kim, H., & Tuttle, N. (2022). Effectiveness of speak-up training programs for clinical nurses: A scoping review. International Journal of Nursing Studies, 136, Article 104375. https://doi.org/10.1016/j.ijnurstu.2022.104375
- National Safety and Quality Health Service. (2021). Communicating for safety figure [Image]. Australian Commission on Safety and Quality in Health Care. https://www.safetyandquality.gov.au/sites/default/files/resources/attachments//nsqhs-communicating-for-safety-figure.pdf
- Omura, M., Maguire, J., Levett-Jones, T., & Stone, T. E. (2017). The effectiveness of assertiveness communication training programs for healthcare professionals and students: A systematic review. International Journal of Nursing Studies, 76, 120–128. https://pubmed.ncbi.nlm.nih.gov/28964979/
- Pattni, N., Arzola, C., Malavade, A., Varmani, S., Krimus, L., & Friedman, Z. (2019). Challenging authority and speaking up in the operating room environment: A narrative synthesis. British Journal of Anaesthesia, 122(2), 233–244. https://www.sciencedirect.com/science/article/pii/S0007091218312819
- Sameera, V., Bindra, A., & Rath, G. P. (2021). Human errors and their prevention in healthcare. Journal of Anaesthesiology Clinical Pharmacology, 37(3), 328–335. https://doi.org/10.4103/joacp.JOACP_364_19
- van Dongen, D et al. (2024). Classification of influencing factors of speaking-up behaviour in hospitals: A systematic review. BMC Health Services Research, 24. https://link.springer.com/article/10.1186/s12913-024-12138-x
- Walsh, S. A., Wirihana, L. A., & Walker, S. B. (2025). A descriptive phenomenological study of the lived experiences of preregistration nursing students who use graded assertiveness to speak up for patient safety during work-integrated learning. Nurse Education Today, 152, Article 106761. https://doi.org/10.1016/j.nedt.2025.106761
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