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example, it would be reasonable to expect these errors to be reduced if drug names were altered and more personnel were hired. Yet, additional room for improvement often remains even after quality gains from system change are realized. Advances in infection control often have been addressed by increasing hand hygiene among caregivers. One relevant system change has been the installation of antibacterial, alcohol-based rub dispensers in patient rooms and near sinks. This change should lead to improved infection control, because alcohol rubs reduce the volume of infection-related microorganisms by 88 percent, compared to hand washing with soap and water, which reduces the volume by only 49 percent.8 The use of information technology (IT) is a key component of system change for error reduction. For example, implementation of “computerized physician order entry” (CPOE) and clinical decision support systems are among specific IT practices recommended to help reduce errors.9 Early evaluations suggest that implementation of CPOE leads to significant improvements in patient safety.10, 11, 12, 13, 14, 15 Thus, a major contributor to medical errors (e.g., physicians’ poor handwriting) is removed from the process. However, despite these promising initial findings, adoption of CPOE has been slow.16 4 Unfortunately, system changes often are not readily embraced by all caregivers. This puts administrators in the uncomfortable position of choosing whether to make protocol improvement voluntary or mandated. Some may see this as a nonissue, saying simply, “Make them do it, or else….” However, this assumption fails to take into account the tendency of forced change to elicit reactance.17 Consistent with widespread calls for improving the health care culture, caregivers need to be supportive of autonomy18 and to feel empowered to change behaviors that could harm their patients. Patient safety can be engineered into a health care system, but peak performance also requires systematic attention to environmental hazards and at-risk behaviors related to patient safety. This paper reviews practical solutions to motivating the adoption and sustained practice of patient safety behaviors that have produced large-scale community and organizational change. In the medical literature, this approach is alluded to simply as “behaviorism” or “behavior modification,” but the technical term should be “organizational behavior management” (OBM). Organizational Behavior Management OBM is defined as the application of behavior analysis to organizational settings.19 The threeterm contingency, or “A-B-C model” (i.e., Antecedent-Behavior-Consequence) is the foundation upon which most behavior-based interventions used by OBM practitioners is developed.17, 20, 21, 22 An antecedent (A) is a stimulus that precedes a behavior (B) and encourages performance of that behavior.22 These can take many forms, such as signs, reminder prompts, or even noises that direct behavior.17 One example of an antecedent strategy shown to be especially useful in improving organizational safety is goal setting (see Locke and Latham23 for a review of the goalsetting literature). A consequence (C) is an event that follows a given behavior and increases the probability the behavior will recur. Like antecedents, consequences can take many forms, such as behavioral feedback, monetary rewards, or a supervisor’s praise for a job well done. For this reason, it can be said that consequences motivate behavior,17 since we tend to act in response to the consequences we expect to receive. Behavior-Based Feedback One type of consequence used in numerous settings to affect behavior change is “feedback.” In general, a feedback intervention involves measuring a targeted behavior and then delivering information (e.g., frequency, rate, or percent correct) about this behavior to relevant individuals or groups. This approach has been shown to successfully increase safe behavior and decrease atrisk behavior in a variety of different nonmedical settings.24, 25, 26, 27, 28 Behavioral Maintenance Establishing desired behavior change during an intervention phase is not sufficient. The longterm
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