Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg

© Author(s) (or their employer(s)) 2022. No commercial reuse. See rights and permissions. Published by BMJ. Since the publication of the 1999 ‘To Err is Human’ report by the Institute of Medicine, healthcare researchers have been attentive to factors potentially associated with iatrogenic risk, or in other words medical care that exacerbates or complicates an existing patient condition. While studies have explored a variety of patient factors (eg, age and weight of neonates) and situational constraints (eg, staffing ratios and healthcare worker (HCW) sleep deprivation ), the risks posed by negative interpersonal interactions in healthcare contexts remain understudied and poorly understood. It is therefore timely that in BMJ Quality & Safety, Guo and colleagues present a systematic review of research examining the effects of unacceptable behaviours between HCWs on clinical performance and patient outcomes. Guo and colleagues’ findings present an important step in raising awareness of the risks posed by negative interpersonal interactions among HCWs, shedding light on how and when such behaviour may indeed serve as a significant iatrogenic risk factor. However, as troubling as their findings may be, they may understate the magnitude and complexity of the challenge that unacceptable behaviours present to HCWs. In this editorial, we begin by commenting on the magnitude of impact that such behaviour has on clinical performance and patient safety, arguing that its true impact is most apparent when considered relative to the magnitude of impact of other iatrogenic risk factors. We then argue that other, largely unexplored, aspects of HCW exposure to unacceptable behaviour may impact clinical performance and patient safety no less than those aspects examined in Guo and colleagues’ review, highlighting (1) the collateral effects of unacceptable HCW behaviour on witnesses and HCW teams, and (2) the effects of unacceptable behaviour directed at HCWs by patients or their families.