Date of Submission


Document Type



Doctor of Education




Patient safety, Error prevention tools, Culture of blame and shame, Capacity building, Organizational culture


In 2010, the Provincial Health Funder (PHF) mandated the reporting of unintentional adverse events that occur in the process of healthcare delivery, which result in disability, death, or prolong treatments. The results of reporting are available to the public on the Health Quality website, providing transparency for the public and accountability for Advanced Healthcare System (AHS)[1], which has made patient safety its organizational strategic priority (AHS, 2018).

This Organizational Improvement Plan (OIP) seeks to improve communication and positive change among healthcare providers by maximizing the use of error prevention tools to improve patient safety. The principles of distributive and transformational leadership are applied to enhance collaboration, build capacity, empower people to speak up for safety, and enhance team decision making. The organizational plan aligns with my leadership philosophy to develop others, as well as abide by the Social Work regulatory body’s ethical standards, which guides my work as a change agent to support the best interest of others.

Systems theory guides the plan and Bolman and Deal’s (2013) four frame conceptual framework is used to enhance the understanding of the existing state of the organization, which currently includes challenges in communication, a culture of “blame and shame”, insufficient use of error prevention tools, and patient harm. The Murray and Richardson (2002) framework is utilized to guide the OIP and identify ten “winning conditions” to address the problem from a holistic standpoint, while encompassing speed and momentum.

Keywords: patient safety, error prevention tools, culture of blame and shame, capacity building, organization culture

[1] Advanced Healthcare System (AHS) is a pseudonym to protect the identity of the facility.