Purpose – This article aims to describe and analyze the results of efforts to improve patient-centered care (PCC) in psychiatric healthcare.

Design/methodology/approach – Using the methodology of a qualitative case study, the authors studied three Swedish child and adolescent psychiatric care (CAP) units in order to describe how patient-centered actions are performed. They conducted 62 interviews, made 11 half-day observations, and shadowed employees for two days.

Findings – The article shows that the increased focus on accountability for unit performance and medical risks results in unintended consequences. The patient’s medical risk is transformed to a personal risk for the psychiatrist and the resource risk is transformed to a personal risk for the unit manager. Patients become risk objects for both psychiatrists and unit managers, which creates an alignment between them to try to send patients elsewhere. New public management (NPM) reforms may consequently lead to the institutionalization of unintended healthcare practices.

Practical implications – The article shows that accountability pressure to reduce patient risk may create new risks for patients.

Originality/value – The study uses theoretical concepts of risk tradeoffs (risk substitution and risk transformation), which were developed for the macro level, to explain the unintended consequences of NPM reforms at the micro level.