CHICAGO (AP) -- Bullying doctors can make nurses afraid to question their performance, resulting in medical errors, according to a hospital group that announced new requirements for cracking down on intimidating behavior.

Outbursts and condescending language threaten patient safety and increase the cost of care, according to a safety alert issued Wednesday by the Joint Commission, an independent organization that accredits most of the nation's hospitals.

Hospitals will be required by next year to have codes of conduct and processes for dealing with inappropriate behavior by staff, said the group's president, Dr. Mark Chassin. Hospitals without such systems risk losing their accreditation, he said.

Powerful doctors mean money for hospitals because they choose where to admit their patients, but they "should not be left off the hook," said Dr. Peter Angood, vice president of the group, which is based in suburban Chicago.

Grena Porto, a nurse involved in the group's efforts, said nurses need to be "appropriately assertive" and feel safe enough to ask a doctor, "Are you sure we're supposed to operate on the right leg, rather than the left?"

Nurses, pharmacists and hospital administrators also can be culprits, but it's the doctors who bully nurses that are the most significant for patient safety, said Dr. Alan Rosenstein, a researcher on the topic. He applauded the group's action.

Rosenstein, medical director of VHA West Coast, an alliance of nonprofit hospitals, surveyed 1,500 hospital employees for a 2005 study published in the American Journal of Nursing, and received comments like these:

• "Most nurses are afraid to call Dr. X when they need to, and frequently won't call. Their patient's medical safety is always in jeopardy because of this."
• “I have caught myself in the middle of mislabeling specimens after confrontations that have been upsetting."

Another survey in 2003 by the Institute for Safe Medication Practices found that 40 percent of health providers said they had kept quiet rather than question a known bully.

Hospitals have pecking orders and are stressful work environments, but "there's a right way and a wrong way to manage that stress," Chassin said.

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