The Institute of Medicine's Crossing the Quality Chasm report endorsed care management, defined as a team-oriented approach to delivery of the appropriate care at the appropriate time and place, through use of decision aids and other tools designed to promote high-quality and safe care. This AHRQ–funded study investigated whether institutions implementing care management achieved improvements in patient safety. No consistent relationship was found between intensity of care management and adverse events. However, several organizational and environmental factors influenced the success of care management efforts, including market managed care penetration and the financial stability of individual hospitals. These factors may explain the apparent discordance between this study's results and those of a prior study, which found that improved performance on patient safety indicators was correlated with intensity of quality improvement efforts.