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influences, but rather as activators for specific kinds of OBM intervention. Behavior is a part of the health care system, which can be targeted for change within a supportive or unsupportive culture. OBM Interventions to Address Medical Errors Behavioral antecedents, including prompts, pledge cards, and communication strategies, as well as consequences, are the primary types of OBM intervention techniques (for a comprehensive description of available OBM techniques, see Geller et al61). The overarching theme of the intervention approach suggested here is to reduce the probability of error by increasing the frequency of safe standards of practice. Several behavioral targets might be relevant for a particular type of medical error, and one target behavior may be related to several categories of error. Table 2 depicts a framework for classifying OBM interventions and specific behavioral targets for error prevention. As the IOM suggests in Crossing the Quality Chasm, “Attention to improving quality includes continuous monitoring, often based on small samples of events that can provide organizations with timely data at the front lines to manage the processes of concern.”62 This is precisely what OBM brings to the domain of patient safety. System-Change Participation Much of the patient safety literature calls for improved incident reporting systems that include less focus on finding fault and greater attention to the context in which the error occurred.2, 3, 63, 64, 65 Adding OBM to this directive could have an immediate positive impact. Winokur and Beauregard38 offer a checklist for ensuring that investigations of caregiver errors are performed with a process focus, placing emphasis on specific task demands and contextual factors, rather than on the identification of individuals at fault. Anonymous error reporting and group feedback can influence individual behavior without assigning personal blame for poor performance. Additionally, improved tracking systems include more uniform, reliable, and freely given closecall reporting. A close call is likely to have been previously paired with negative feelings, such as guilt, shame, or fear, thus leading to underreporting of close calls or “near misses.” Increasing the quantity and quality of close call reports is a critical behavioral target for OBM. The close call report should be portrayed as an event of success, whereby one or more holes in the system can be fixed and thereby prevent harm to a patient. The best way to support close-call reporting is to visibly show knowledge gained from the report, which might be a change in the system that prevents similar errors from occurring.64 In other words, the close call report should be treated as a trophy for patient safety. It offers the kind of feedback needed to develop a corrective action plan, and it suggests a possible target for an OBM intervention. 10 Table 2. Proposed framework of behaviors to target for error prevention Patient safety outcome category Potential behavior targets Antecedent strategies Consequence strategies Relevant literature Patient-HCW communication error • Patient-centered communication • Patient education for increased prompts/questions • Patient rating feedback Burroughs et al66 Larkin et al67 HCW-HCW communication error • Communication of change in status of care • Prompts on transcription order and patient transfer forms • Appreciative Inquiry training • Praise • Communicationstyle feedback Rotstein et al45 Shendell-Falik et al47 Wachter3 Diagnosis error • Complete diagnosis protocol compliance • Written prompts, checklists, etc. • Peer observational feedback Geller17 Infection-control error • Hand washing • “Hands-free” exchanges of sharps • Glove use • Goal-setting • Prompting • Task-clarification (modeling) • Incentive • Feedback • Supervisor praise • Reward Cunningham & Austin37 Babcock et al33 Devries et al34 Watson et al68 Stephens & Ludwig35 Mayer et al40 Sharek et al41 Randle et al42 Decubitus ulcer monitoring error • Increased checking of inpatients for decubitus ulcers • Monitoring forms or behavioral checklists • Decubitus ulcer incidence rate feedback • Supervisor praise Geller & Johnson31 Failure to rescue monitoring error • Vigilance
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