Anaesthesia
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'Speaking up' or the ability to effectively challenge erroneous decisions is essential to preventing harm. This mixed-methods study in two parts explores the concept of 'barriers to challenging seniors' for anaesthetic trainees, and proposes a conceptual framework. Using a fully immersive simulation scenario with unanticipated airway difficulty, we investigated how junior anaesthetists (one to two years of training) challenged a scripted error. ⋯ Focus group analysis conceptualised a 'barrier network' with three main themes: concerns around relationships; decision-making; and risk/cost-benefit. Emotional maturity is an important protective layer around decisions to challenge. Despite significant multifactorial barriers, systematic training in effective 'speaking up' could improve the confidence and ability of juniors to challenge erroneous decisions.