The need for organizational change in patient safety initiatives

James G. Anderson, Rangaraj Ramanujam, Devon Hensel, Marilyn M. Anderson, Carl A. Sirio

Research output: Contribution to journalArticle

45 Scopus citations


Objectives: This study describes a computer simulation model that has been developed to explore organizational changes required to improve patient safety based on a medication error reporting system. Methods: Model parameters for the simulation model were estimated from data submitted to the MEDMARX medication error reporting system from 570 healthcare facilities in the U.S. The model's results were validated with data from the Pittsburgh Regional Healthcare Initiative consisting of 44 hospitals in Pennsylvania that have adopted the MEDMARX medication error reporting system. The model was used to examine the effects of organizational changes in response to the error reporting system. Four interventions were simulated involving the implementation of computerized physician order entry, decision support systems and a clinical pharmacist on hospital rounds. Conclusions: Results of the analysis indicate that improved patient safety requires more than clinical initiatives and voluntary reporting of errors. Organizational change is essential for significant improvements in patient safety. In order to be successful, these initiatives must be designed and implemented through organizational support structures and institutionalized through enhanced education, training, and implementation of information technology that improves work flow capabilities.

Original languageEnglish (US)
Pages (from-to)809-817
Number of pages9
JournalInternational Journal of Medical Informatics
Issue number12
StatePublished - Dec 2006


  • Incident reporting systems
  • Medical errors
  • Organizational change

ASJC Scopus subject areas

  • Medicine(all)

Fingerprint Dive into the research topics of 'The need for organizational change in patient safety initiatives'. Together they form a unique fingerprint.

  • Cite this