MHA 601: Principles of Healthcare

Case Study: Improving Responses to Medical Errors with Organizatio nal Behavior Management

A 146-bed general acute care community hospital in southwest Virginia conducted an

assessment of patient safety needs and the various organizational behavioral management

techniques used by hospital managers in response to the nine most frequently reported patient

safety events. The most frequently reported category of patient safety events (errors) was

procedure/treatment variance, and the least effective management responses were to witnessed

falls. The organizational behavioral management intervention therefore selected managers’

follow-up responses to procedure/treatment variance and witnessed falls as targets.

Managers first received the results of the needs assessment, then were instructed to (a) respond to

the two targeted event types with corrective-action communication combined with individual and

group behavior-based feedback and (b) use positive recognition to support behavior that

prevented harm, including reporting events. For the 3-month intervention period, researchers

Cunningham and Geller (2011) reviewed 361 patient safety event follow-up descriptions, with a

total of 527 interventions that achieved the following results:

Reports of targeted event types increased in the first month of intervention, then decreased in

subsequent months, indicating that the intervention increased employees’ sensitivity to the need

to report close calls and learn from them.

The two targeted events displayed opposite trends in impact scores associated with managers’

follow-up actions during the intervention phase. The impact scores for follow-up behaviors for

procedure/treatment variance increased sharply in the first month, then gradually declined in the

next 2 months. In contrast, impact scores for follow-up behaviors for witnessed falls increased

slightly in month one, then sharply in subsequent months.

Managers significantly increased use of individual and group feedback during the intervention

phase and decreased use of no intervention, a significant improvement in the management of

patient safety errors. Especially significant was the increased use of group feedback.

Participating managers and health care workers expressed positive perceptions of the

intervention techniques used and related outcomes. Managers received summaries of the monthly

events and intervention follow-up reports at monthly managers’ meetings and were encouraged

to share them with their employees. Intervention perception survey results found that both

managers and workers perceived an increase in managers delivering praise for behaviors to

prevent harm than delivering reprimands for errors.

This study demonstrates the benefits of applying an evidence-based intervention strategy by

teaching health care managers to (a) communicate more effectively in follow-up responses to

patient safety events, (b) more carefully document their follow-up actions to learn what

intervention behaviors do most to promote patient safety, and (c) provide group rather than

individual feedback when appropriate. This intervention demonstrably improved patient safety

and offers a model for managers in other organizations to follow.