Establishing specific criteria to sound the rapid- response alarm can help bolster the resolve of a nurse working alone late at night, says James Bagian, M.D., a longtime patient safety expert based at the University of Michigan, Ann Arbor. "It takes away some of the source of concern about embarrassment, ridicule or humiliation," he says.

But hospital leaders also should strive to create a work environment in which a nurse feels comfortable speaking up, even when vital signs don't fall neatly into one of the criteria groups, Bagian says. Otherwise, a few unkind words from a physician might jeopardize patient safety the next time that nurse considers activating the team.

One recurring theme in these sorts of communication foul-ups and hurt feelings is the differing communication styles of doctors and nurses, says Kathy Duncan, R.N., a faculty member at the Institute for Healthcare Improvement. "Nurses are more narrative than doctors," she says, adding that they do a lot of "hoping and hinting around. Doctors want to hear the bullet points."

Thus, a nurse, after waking up Dr. Jones, might raise her concerns indirectly, saying that the patient looks "a little fluidy," rather than suggesting the need for a chest X-ray and a diuretic. The weary physician, as the narrative stretches and the clock ticks by, might become impatient and the exchange can unravel from there.

Physicians typically prefer the nurse to compile all of the relevant information and swiftly lay out the scenario, along with any recommendations. "Doctors all over the country have told me this," Duncan says. "Even if the recommendation is wrong, it gives them a picture of what I am seeing."

Hospital administrators also can play a role, making their support for nurses and other staffers crystal clear, says Christiane Levine, a quality manager at Children's Healthcare of Atlanta. When the pediatric system launched its team, leaders also rolled out an educational campaign, stating that they wouldn't stand for any blowback from anyone, including medical residents and attending physicians. Nurses and other staffers were told: "If you are speaking up on behalf of the patient, we will stand behind you. And, if you get an ugly response from somebody, let us know because we will stand behind you."