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behaviors • Prompts for patient checks • Response time feedback Geller & Johnson31 Surgical treatment error • Upward communication among team members • CRM training • Team perception survey feedback • Peer-to-peer coaching Geller & Johnson 31 Gordon69 Salas et al70 Technical procedure treatment errors • Recommended practice compliance • Written policy statements • Reminders • Peer-to-peer coaching Geller17 System-change errors • Adoption of CPOE • Error reporting • Software user training • Public reminders • Education on use of error reports • Anonymous reporting reminders • SCF • Technology incentive • Recognition with corrective action • Rewards Levick et al39 Cunningham et al16 Boyce & Geller29 Force et al71 Larkin et al72 HCW = Health care worker; CRM = Crew resource management; CPOE = Computerized physician order entry; SCF = Social-comparison feedback 11 Another key target behavior for patient safety is the adoption of emerging technologic innovations. Implementing CPOE is more easily accomplished with hospital-employed caregivers rather than with professionals operating under contract, because more immediate contingencies are available for these individuals. Increasingly intense levels of intervention are needed for individuals resistant to adopting system changes such as CPOE. Incentive and reward strategies have increased this target behavior, but other strategies such as promise card commitments may be more effective in the long term, since this approach tends to be perceived as imposing less external control and promoting self-persuasion.18, 65 Social comparison feedback29 (SCF) is another OBM option for intervening with groups and individuals resistant to adopting system changes. SCF involves providing caregivers with objective data comparing their own use of patient safety devices or methods with that of their peers. It should be most effective for groups with more individualistic and competitive tendencies. Diagnosis Errors Diagnosis errors are among the most difficult to address because despite system changes, they remain devastating in terms of their overall high frequency of occurrence and potential to harm patients. Furthermore, diagnosis is mainly the responsibility of physicians. One technique already being used in the training of symptom identification is a behavioral checklist. Following training, the trainer’s checklist becomes a mental checklist to direct the behavior of a skilled caregiver. A variation of the behavioral checklist for training is the behavior-based observation and feedback process, which has dramatically reduced injury rates in numerous industrial applications.17, 65 This OBM process involves workers in the development of a checklist of critical safety-related behaviors for a particular task. Subsequently, the checklist is used to conduct systematic peer-to-peer behavioral observations, followed by a review of the checklist data. Both the observer and the person observed learn valuable error-reduction information throughout this peer-to-peer coaching process. Furthermore, the very act of observing another’s behavior has been demonstrated to increase the observer’s performance of desired behavior.73 This is a paradigm shift from the “see one, do one, teach one” aphorism5 to continuous learning. Treatment Errors Some types of treatment errors may lend themselves to direct observation and feedback. Many complicated surgical procedures, which are problematic in terms of frequency and severity, provide a clear opportunity for peer-to-peer coaching. Often, observation is already sought for highly complicated cases among surgeons and for hands-on training of caregivers. However, there are no known reports of the regularity with which such strategies are used for more common types of health care procedures performed by experienced caregivers. Peer-to-peer coaching can also ensure compliance with recommended practices and offer opportunities for corrective feedback. In the context of a patient safety culture looking for 12 success, this is a learning opportunity rather than an event to be dreaded and avoided. The observation and feedback process also fits with
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