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referred to as the “not-invented-here” syndrome.49 Generalizations about psychologists also may be a barrier to the acceptance of OBM techniques by health care professionals, since such consultants might be perceived as trying to fix the “mentally ill” caregiver. From a physician’s or administrator’s standpoint, one might even speculate that an OBM consultant might share potentially damaging data with the public. The patient safety literature often contains rather illustrative case examples of how particular errors led to dramatically adverse events for patients.3 This emphasis on the case study outcome stands in contrast to the OBM paradigm, which focuses on objective behavioral data gained from several systematic observations of the process. In addition, standards of valid evidence differ between the fields of medicine and OBM. In medicine, the results of randomized, controlled trials from different institutions are considered to be evidence of the highest grade, whereas observational studies within the same institution are viewed as having less validity because they 50 reportedly overestimate treatment effects. Conversely, in OBM research, the multiple-baseline 8 design,51 employing nonequivalent controls, is the most frequently used evaluation methodology. Health Care Organizational Structure Within the vertical hierarchical structure that tends to be the norm in health care settings, differences in levels of authority contribute to many communication errors.52 In addition, the hierarchical structure that characterizes interprofessional communication among caregivers can limit valuable interpersonal feedback related to patient safety.53 In fact, such occupational hierarchies have led to a low frequency of error reporting and corrective action. Practitioners are hesitant to report errors or incidents to senior colleagues because of “cultural taboos” associated with error reporting and the possible detriment to career advancement.54 Junior practitioners do not want to seem incompetent or offend those in power.52 Expected and actual negative consequences from error-related communications serve to reduce such reporting and limit learning from mistakes. The uncertainties of the health care profession have caused physicians to accept risk55 and to view error as an unavoidable and necessary feature of their work.56, 57, 58 It has even been argued that errors and mistakes play a necessary role in the learning process of training programs.59 In contrast, the OBM practitioner does not view an error as an unavoidable accident from which to learn, but rather as an instance of contingencies failing to influence appropriate behavior. Medical Errors to Target with OBM Errors Remaining After System Change It is acknowledged that several types of errors are already being addressed by well-informed system-based changes, but a number of categories of errors persist. These include technical errors during care procedures, failures in communication among caregivers and between provider and patient, contamination errors due to ineffective employee and patient hygiene, and lapses in patient monitoring. To be of maximum benefit to medical professionals and OBM practitioners, the categories of errors discussed here are based on already established classification methods and priority areas (e.g., Table 1; The 100,000 Lives Campaign60). Also, given the aim of proactive measurement and intervention, they are process- rather than outcome-based and include: • Diagnosis errors, such as using the wrong test, delays in diagnosis, and failing to act as indicated on test results. • Treatment errors, such as ordering a wrong drug or dosage, accidental puncture or laceration, and incorrectly executing a procedure. • Monitoring errors, such as bedsores, failure to rescue, and patient falls. • Infection-control errors, such as failing to wash hands, lack of glove use, and compromising sterile-field maintenance. • Communication errors, such as failing to inform other caregivers of acute risk, changes in care, and critical hand-off information, as well as ineffective communication with patients. 9 These intervention targets are not identified as independent of system
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