Kotter’s Change Model for Ensuring Patient Safety


Patient health outcomes depend not only on the qualifications of medical personnel or the severity of a disease but also on other aspects that are crucial to control. One of the issues in acute care settings is the need to ensure patient safety in medication used. This problem affects the quality of medical care negatively and is a critical challenge to overcome. As a change framework for quality improvement in accordance with evidence-based research, Kotter’s change model will be used as a practice that allows planning the necessary work in stages and implementing relevant interventions to eliminate the issue effectively. As an assessment, the incidence of medication errors will be compared with the rates before the introduction of the change model. The role of nursing staff in this work is significant, and when positive outcomes are achieved, appropriate rewards are valuable motivating tools. Kotter’s change model is an effective methodology for reducing the number of medication errors in an acute clinical setting and improving the quality of care.

Problem Identification

Poor drug administration is a problem that deserves particular attention from both hospital managers and national regulation boards. According to Bucknall et al. (2019), from 5% to 10% of all mistakes made by medical personnel are related to ineffective control over patient medication intake (p. 1317). In an acute clinical setting, the situation is exacerbated by the fact that patients are usually unable to interact with nurses and physicians due to severe conditions. As one of the reasons, Bucknall et al. (2019) call a weak organizational culture that affects the insufficient concentration of personnel on performing their immediate duties responsibly. As a result, patient safety is jeopardized since improper medication administration can lead to dangerous outcomes, for instance, intoxication or even death. In addition, the credibility of the healthcare industry is reduced due to unskilled employees who make mistakes. Therefore, the introduction of an appropriate change model to address the problem in question is a significant perspective.

Kotter’s Change Model

Evidence-based research is a method that allows identifying a suitable improvement framework to solve the problem of patient safety in medication used. Based on the assessment of relevant academic studies, Kotter’s change model is proposed as a convenient and efficient algorithm that helps improve the performance of medical personnel (Mohiuddin & Mohteshamuddin, 2019; Small et al., 2016). According to Mohiuddin and Mohteshamuddin (2019), this algorithm is an eight-step program that promotes workplace behavior change and a sense of personal work responsibility. Small et al. (2016), in turn, argue that this model makes it possible to develop a plan that addresses all the necessary nuances, from promoting a sense of urgency in the team to maintaining the achieved results within a single environment. For acute care settings, Kotter’s framework implies communicating the importance of proper medication control to employees, involving all stakeholders, achieving short-term goals, overcoming intermediate barriers, and some other activities aimed to implement a program for the transition to more productive work.

Measuring the Effectiveness of the Change Model

As the main criteria for assessing the effectiveness of the proposed change model, the indicators of medication administration before and after the framework implementation within an individual acute care setting will be considered. In case the percentage of errors is lower after the introduction of the intervention program, this will prove the value of Kotter’s model and make it possible to assert its importance as a method for stimulating an increase in organizational culture among medical personnel. As Small et al. (2016) note, this framework is easy to follow since it is structured and allows motivating employees through active engagement. For the assessment, data on the number of medication errors allowed will be collected, and baselines will be compared by conducting simple statistical calculations. This practice is a convenient and productive approach that provides accurate information about the success of the intervention.

Importance of Rewarding Nurses

To stimulate the productive activities of nursing staff and reward employees for participating in the change program, material bonuses are a significant reward. Lennon and Fallon (2018) remark that financial incentives are perceived by personnel as an effective motivator that allows each team member to feel one’s own importance and engagement in achieving a common goal. For nurses in acute clinical settings, the work is associated with a constant burden and high responsibility. Financial incentives are a convenient form of promoting high professional performance, preventing burnout in the workplace, and minimizing medication errors that endanger patient safety.


Introducing the Kotter’s change model into the work environment in acute clinical settings allows addressing the issue of ensuring patient safety in medication used. This framework is a convenient and effective mechanism that helps implement an intervention program and engage staff in continuous activities aimed to improve operational results. Patient safety is a parameter that determines the quality of care and depends on numerous factors, and improper or weak drug administration control is one of the negative drivers that worsen patient health outcomes. As a potential motivator, financial bonuses for nurses are valuable incentives that increase productivity and maintain high employee engagement.


Bucknall, T., Fossum, M., Hutchinson, A. M., Botti, M., Considine, J., Dunning, T., Hughes, L., Weir-Phyland, J., Dugby, R., & Manias, E. (2019). Nurses’ decision‐making, practices and perceptions of patient involvement in medication administration in an acute hospital setting. Journal of Advanced Nursing, 75(6), 1316-1327. Web.

Lennon, R., & Fallon, A. (2018). The experiences of being a registered nurse prescriber within an acute service setting. Journal of Clinical Nursing, 27(3-4), e523-e534. Web.

Mohiuddin, S., & Mohteshamuddin, K. (2020). Combination model for sustainable change by utilizing the Kotter’s change model and the Hersey & Blanchard’s leadership model for improving medication errors reporting. Journal of Medical & Allied Sciences, 10(1), 25-32. Web.

Small, A., Gist, D., Souza, D., Dalton, J., Magny-Normilus, C., & David, D. (2016). Using Kotter’s change model for implementing bedside handoff: A quality improvement project. Journal of Nursing Care Quality, 31(4), 304-309. Web.

Video Voice-over

Cite this paper

Select style


NursingBird. (2023, October 25). Kotter’s Change Model for Ensuring Patient Safety. Retrieved from https://nursingbird.com/kotters-change-model-for-ensuring-patient-safety/


NursingBird. (2023, October 25). Kotter’s Change Model for Ensuring Patient Safety. https://nursingbird.com/kotters-change-model-for-ensuring-patient-safety/

Work Cited

"Kotter’s Change Model for Ensuring Patient Safety." NursingBird, 25 Oct. 2023, nursingbird.com/kotters-change-model-for-ensuring-patient-safety/.


NursingBird. (2023) 'Kotter’s Change Model for Ensuring Patient Safety'. 25 October.


NursingBird. 2023. "Kotter’s Change Model for Ensuring Patient Safety." October 25, 2023. https://nursingbird.com/kotters-change-model-for-ensuring-patient-safety/.

1. NursingBird. "Kotter’s Change Model for Ensuring Patient Safety." October 25, 2023. https://nursingbird.com/kotters-change-model-for-ensuring-patient-safety/.


NursingBird. "Kotter’s Change Model for Ensuring Patient Safety." October 25, 2023. https://nursingbird.com/kotters-change-model-for-ensuring-patient-safety/.