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Within the team there needs to be a hierarchy. This is the ‘power gradient’; the leader is at the top of this as the person coordinating, directing and making the decisions. However, this should not be absolute. There is much discussion in the literature about the degree of the hierarchical gradient. If it is too steep the leader has a massive position of power, his or her decisions are unquestionable and the followers blindly follow the orders. This is not safe because leaders are humans too and also make errors – their team is their safety net.

Safe practice is achieved where the followers feel they can raise concerns or question instructions. This must always be understood by the leaders as much as by the followers. One way to reduce the hierarchy gradient is for the leader to invite the team’s thoughts and concerns, particularly around patient safety issues. It is also important for the follower to learn how to raise concerns appropriately. This is often referred to as ‘flattening the hierarchial pyramid’ – the leader is ‘nearer’ to his/her team, actively listening to concerns raised, whilst team members undertake allocated tasks effectively and feel empowered to ‘challenge’ or raise concerns.

One acronym that is sometimes used to raise concerns in a format which escalates appropriately is PACE (probe, alert, challenge and finally declare an emergency). The probing question allows diplomacy and maintenance of the hierarchy whilst raising the relevant concern.

Stage	Level of concern
P Probe	’Do you know that …’
A Alert	’I’m more concerned now …’
C Challenge	’Please stop what you’re doing and consider …’
E Emergency	’I need you to stop immediately because …’

These stages are described with examples below:

 Probe – this is used where a person notices something they think might be a problem. They verbalise the issue, often as a question. ‘Have you noticed that this woman is bleeding excessively?’

 Alert – the observer strengthens and directs their statement and suggests a course of action. ‘Dr Brown, I am concerned, the mother is still bleeding more than I’d expect – shall I give ergometrine?’

 Challenge – the situation requires urgent attention. One of the key protagonists needs to be directly engaged. If possible the speaker places him‐ or herself into the eye line of the person they wish to communicate with. ‘Dr Brown, you must listen to me now, this patient needs more action now as the bleeding is not slowing down.’

 Emergency – this is used where all else has failed and/or the observer perceives a critical event is about to occur. Where possible a physical signal or physical barrier should be employed together with clear verbalisation. ‘Dr Brown, you are not acting on this woman’s significant ongoing bleeding. Please move aside and I will assess directly myself.’

The PACE structure can be commenced at any appropriate level and escalated until a satisfactory response is gained. If an adverse event is imminent then it may be relevant to start at the declaring ‘emergency’ stage, whereas a much lower level of concern may well start at a ‘probing’ question.

Some industries have also additionally adopted organisation‐wide critical phrases that convey the importance of the situation, e.g. ‘I am concerned’, ‘I am uncomfortable’ or ‘I am scared’. In an effective team where the leader actively listens to concerns raised by his/her team members, progressing beyond the ‘P’ or ‘A’ step should rarely be needed.