Speaking Up for Safety

Speaking Up for Safety: Two Challenge Rule and CUS

Speaking up for safety can be difficult depending on the circumstances, staff involved, receptivity of the individual(s) being questioned, and overall existing culture. In situations when there is a concern for patient safety, an error is noted, or more clarity is needed around a plan of care, using clear language in a simple and direct manner can be helpful. Structured communication tools can help guide conversations in these scenarios, and examples of these include the two challenge rule and CUS (AHRQ, 2012). This article will discuss these tools in more detail. 

Two Challenge Rule

The two challenge rule is a structured way to communicate concerns in a respectful manner. The idea here is that concerns are voiced initially two times, either by the same or different team members. The first challenge involves asking a question, and if this is ignored, the second challenge involves asking for further clarification with more information provided. The goal is for the individual being challenged to respond, and if this does not occur, then continued action is necessary to resolve the situation including going to a supervisor or using the chain of command (AHRQ, 2012). For example, a nurse questions a doctor’s order for regular insulin 60 units. The first challenge is a question about the dosage. The second challenge gives more information: “Dr. Smith, we don’t typically give 60 units of regular insulin for sliding scale coverage”. The doctor responds with “I meant to give an order for 6 units instead”. 


CUSCUS is an example of another advocacy tool, and represents the following words: 

I am Concerned

I am Uncomfortable

This is a Safety issue (AHRQ, 2012)

This tool provides a scripted way to have a conversation regarding a concerning situation and allows any team member to “stop the line”, or halt the situation, until further clarification is received. For example, a patient has reached the threshold for treatment for severe hypertension. The nurse notifies the physician who decides the plan is to continue to monitor. Using the CUS tool, the nurse may respond with “I am concerned because my patient has had several blood pressures within severe range. I’m uncomfortable with the plan to continue to monitor because, according to our guidelines, she has met the criteria for treatment with antihypertensive agents. This is not safe.” 

Putting these Tools into Practice

Establishing an environment that is open and receptive to this communication is key to these tools being effective. What might this look like?  Introducing these approaches, as part of a team training program, such as the Agency for Healthcare Research and Quality TeamSTEPPS program, is one example of how the concepts can be introduced. Multidisciplinary simulation can be used to reinforce and practice the behaviors and help team members get comfortable with the language. In addition, real-time role modeling by leaders can help to bring these tools into the clinical environment. The end goal is that there is buy-in from all staff involved, support for the approach, and everyone is on the same page. 

In summary, the two challenge rule and CUS are advocacy tools that can help guide conversations when there is a concern for patient safety, an error is noted, or more clarity is needed around a plan of care. These tools are most effective when staff buy-in is established and the overall environment is receptive to this type of advocacy. 

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide


Agency for Healthcare Research and Quality (2012). Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS®)  2.0. Agency for Healthcare Research and Quality. TeamSTEPPS Fundamentals Course: Module 6. Mutual Support. (n.d.). Retrieved from https://www.ahrq.gov/teamstepps/instructor/fundamentals/module6/igmutualsupp.html

Agency for Healthcare Research and Quality (2013). Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS®) 2.0. Pocket Guide. Retrieved from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.pdf

4 thoughts on “Speaking Up for Safety: Two Challenge Rule and CUS”

  1. Love This. In OB, especially, we can run into some issues where someone sees something a different way than another person. I have personally “cus”ed at providers in the past and it works well. It’s professional, but also helps the provider see what you are seeing. Thanks, Jeanette!

    1. I can’t agree more! OB is especially difficult because there are so many grey areas of interpretation. Staff need to be empowered to speak up, within a culture that is receptive to the conversation. The tools keep the conversation simple and direct, and take the emotion out of it.

  2. Deanna Starr Williams MSN, RN

    This is a very well done! Thank you!! We just discussed using CUS in our education meetings!! I plan to share this article with staff.

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