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Organizational Behavior Management in Health Care: Applications for Large-Scale Improvements in Patient Safety Thomas R. Cunningham, MS, and E. Scott Geller, PhD Abstract Medical errors continue to be a major public health issue. This paper attempts to bridge a possible disconnect between behavioral science and the management of medical care. Epidemiologic data on patient safety and a sampling of current efforts aimed at patient safety improvement are provided to inform relevant applications of organizational behavior management (OBM). The basic principles of OBM are presented, along with recent innovations in the field that are relevant to improving patient safety. Safety-related applications of behaviorbased interventions from both the behavioral and medical literature are critically reviewed. Potential OBM targets in health care settings are integrated within a framework of those OBM techniques with the greatest possibility of improving patient safety on a large scale. Introduction Organizational behavior management (OBM) focuses on what people do, analyzes why they do it, and then applies an evidence-based intervention strategy to improve what people do. The relevance of OBM to improving health care is obvious. While poorly designed systems contribute to most medical errors, OBM provides a practical approach for addressing a critical component of every imperfect health care system—behavior. Behavior is influenced by the system in which it occurs, yet it can be treated as a unique contributor to many medical errors, and certain changes in behavior can prevent medical error. This paper reviews the principles and procedures of OBM as they relate to reducing medical error and improving health care. First, we need to define medical error. This task is neither simple nor straightforward because the definition of a medical error varies markedly across different hospitals and health care systems. For example, the National Patient Safety Foundation1 defines a “health care error” as: “[A]n unintended health care outcome caused by a defect in the delivery of care to a patient.” According to the Institute of Medicine (IOM), a health care error is “a problem in the process of care itself or failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim.”2 Thus, while some refer to medical error as any act, or failure to act, which results in harm to a patient, others refer to medical error as any action within the process of care that may have the potential to cause harm. This latter prevention-focused definition best fits the application of OBM. This distinction is relevant to interpreting the patient safety literature, since research results typically focus on frequencies of adverse events (outcomes) rather than process-level errors (or 1 behaviors) occurring during health care. However, a single error does not guarantee that a patient will experience a medical injury. An examination of case studies of errors presented in the Annals of Internal Medicine suggests as many as 17 separate individual errors may occur before a patient is actually harmed.3 Thus, process measures need to be addressed in designing patient safety programs. Dimensions of Medical Errors The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators4 (PSIs) are the most commonly used measures of patient safety performance. They include 16 classes of patient safety incidents (Table 1). Although this is a useful classification system, prevention requires a specification of actions leading to these types of patient safety incidents. Leape5 has provided a brief and practical typology of medical errors that includes four main domains: 1. Diagnostic. 2. Treatment. 3. Preventive. 4. Other. Within these domains is a more specific list of 14 types of errors that can be seen as a
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