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Making a Case for Organizational Change in Patient Safety Initiatives.


In: Henriksen K1, Battles JB1, Marks ES2, Lewin DI1, editors.


Advances in Patient Safety: From Research to Implementation (Volume 2: Concepts and Methodology). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.
Advances in Patient Safety.

Author information

Agency for Healthcare Research and Quality
US Department of Defense
Krannert School of Management, Purdue University (RR). RAND-University of Pittsburgh Health Institute (DK). University of Pittsburgh Schools of Medicine and Pharmacy (CS)


Objectives: Widespread organizational change is indispensable for significantly improved patient safety. This paper discusses critical issues in effective change management, drawing attention to the unintended consequences of pursuing patient safety without effective change management. It includes pointers from organizational change literature on critical issues in managing change, such as how change is defined, what the roles are of different participants, and how change is implemented and made self-sustaining. We make some preliminary observations about mismanaged change processes in patient safety initiatives.Conclusions: The challenge of patient safety is not only clinical, but also organizational. To succeed, patient safety initiatives must be designed and executed using change management principles such as congruent changes targeting multiple components, specific change management roles for different participants in the care-delivery process, implementation through dedicated support structures and multiple tactics, and institutionalization through enhanced workforce capabilities and opportunities for continuous learning. The costs of mismanaging change go beyond the failure of patient safety initiatives—they include hardened employee skepticism toward calls for increased patient safety.

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