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What’s New in the Patient Safety World

January 2020

ISMP Canada: Change Management to Prevent Recurrences



Lots of work gets done on root cause analyses (RCA’s). But then we often fail to undertake the necessary steps to ensure that any solutions or interventions or strategies we recommended actually take place and are effective.


ISMP Canada recently had a simple, but practical, article on change management (ISMP Canada 2019). They described the steps taken by a hospital in response to two fatal pediatric incidents involving concentrated potassium solutions. One incident involved the inadvertent use of concentrated potassium phosphate solution to flush an intravenous line; the other involved a preparation error that resulted in the patient receiving 10 times the required amount of potassium chloride intravenously.


The key steps in any change management program include:

-        Recognizing the need for change

-        Building a multidisciplinary team to guide change

-        Developing strategies to reinforce change

-        Communicating strategies to promote buy-in

-        Anchoring the change in organizational policies and procedures

-        Incorporating continuous monitoring and assessment



Recognizing the need for change

In the case presented, there was a compelling story that change was needed. But that is not always the case. You’ve heard us over and over stress “stories, not statistics”. People are much more likely to recognize the need to change when they hear a compelling story that makes them say “Wow. That could happen here!” It’s easier to make everyone recognize the need for change when a serious incident occurs at their facility. But telling a heartfelt story about a serious incident at another organization can also make everyone recognize the need for change. We find it particularly helpful when a healthcare worker involved in one of those serious incidents can tell their story about how it affected them as well as the patient or family involved.



Building a multidisciplinary team to guide change

Since change management almost always involves change at every level of your organization, it is key to assemble a multidisciplinary team truly representative of stakeholders. Not only are multiple stakeholders likely to contribute to development of change strategies, but they are also more likely to facilitate buy-in from their respective disciplines once you have developed change strategies.



Developing strategies to reinforce change

Sounds like the obvious next step. But be careful not to jump right in. Those of you involved in quality improvement who use the model espoused in The Improvement Guide (Langley 1996) know that the key question after you identify something you want to change is “How will we know that the change is an improvement?”, i.e. how will we measure the effects (both intended and unintended) of our efforts.


The three fundamental change questions (Langley 1996):

-        What are we trying to accomplish?

-        How will we know that a change is an improvement?

-        What changes can we make that will result in improvement?


Remember also that there is a hierarchy of actions that are likely to help you succeed in fixing your problem. We hope you’ll go back to our March 27, 2012 Patient Safety Tip of the Week “Action Plan Strength in RCA’s for a discussion of which actions are likely to be successful and which are not. That column includes a link to our more graphic representation of action plan strengths.


At the hospital discussed in the ISMP Canada bulletin, one of the key goals was to reduce individualized prescriptions for intravenous electrolyte solutions (which were necessitating the use of concentrated electrolyte solutions). Strategies developed to support this goal included targeting different aspects of the medication-use process and engaging multiple health care providers. For example, preprinted and computerized order sets were modified to support the safe prescribing of electrolytes by including alternatives to intravenous electrolytes for certain clinical situations.


You should all recognize that the strongest actions are restraints and forcing functions. To prevent accidents with concentrated electrolyte solutions, the strongest action is to remove such solutions from any area that does not have an absolute need for them. That may have prevented the first described incident (where a concentrated potassium solution was inadvertently used to flush an IV line). But in the second incident, the pharmacy would have needed access to the concentrated solutions in order to prepare the prescribed electrolyte solution.


Communicating strategies to promote buy-in

The ISMP Canada bulletin has a really important point here: involvement of direct care providers, as well as managers and administrators, contributes to staff empowerment and promotes buy-in for the change.


It then notes that change strategies should include appropriate education and training for all those involved. Be careful there. If you looked at our slide set mentioned above, you’d have seen that education and training rank as the least effective actions. While education and training are necessary in most change projects, they should never be your sole or most important action. Timely in that regard is an excellent recent editorial by Soong and Shojania “Education as a low-value improvement intervention: often necessary but rarely sufficient” (Soong 2019). It describes several scenarios and how education fits in with each.


Perhaps the real goal of communication strategies is to generate buy-in. As we have stressed over and over, you need to look for noise any time you are promoting a change project. By “noise” we mean sentiment against change. That may be overt or covert. The grumbling in your medical staff lounge is important. We always say “If you do not encounter noise early on, your change project is doomed.” You need to recognize such sentiment and work to make all stakeholders recognize why the change is needed and how the recommended actions will help achieve the desired goals.



Anchoring the change in organizational policies and procedures

The ISMP Canada bulletin notes that change must be anchored within the organizational culture, and the new standard of practice must be sustained through regular reinforcement, which may include celebration of each successful step in the process of change.



Incorporating continuous monitoring and assessment

As we noted above the key question after you identify something you want to change is “How will we know that the change is an improvement?”. So, you should have developed a measurement strategy that will assess your progress toward meeting the new goals. And, equally important, you must be vigilant for unintended consequences. Even the best thought-out strategies often lead to unintended consequences that may be detrimental.


Sometimes it is difficult to measure some undesirable outcomes. For example, in the ISMP Canada scenario, you don’t want to have any incidents related to concentrated electrolyte solutions. So, you may have to look at surrogate measures. The hospital in the ISMP Canada article measured use of vials of concentrated potassium solutions, looking for a reduction in such use.



There’s nothing new and earth-shattering in the ISMP Canada article. But it serves as a good reminder about facilitators and barriers to any change management project.




Some of our prior columns on RCA’s, FMEA’s, response to serious incidents, etc:

July 24, 2007              Serious Incident Response Checklist

March 30, 2010           Publicly Released RCA’s: Everyone Learns from Them

April 2010                   RCA: Epidural Solution Infused Intravenously

March 27, 2012           Action Plan Strength in RCA’s

March 2014                 FMEA to Avoid Breastmilk Mixups

July 14, 2015              NPSF’s RCA2 Guidelines

July 12, 2016              Forget Brexit – Brits Bash the RCA!

May 23, 2017              Trolling the RCA

October 2019               Human Error in Surgical Adverse Events






ISMP Canada. Change Management in Response to Preventable Tragedies. ISMP Canada Safety Bulletin 2019; 19(10): 1-5 December 12, 2019



Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP, The Improvement Guide. A Practical Approach to Enhancing Organizational Performance. San Francisco: Jossey-Bass Publishers, 1996



Soong C, Shojania KG. Education as a low-value improvement intervention: often necessary but rarely sufficient. BMJ Quality & Safety 2019; Published Online First: 16 December 2019





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