Following implementation of the web-based Targeted Solutions Tool in a 12-hospital health system, hand hygiene rates improved from a baseline rate of 58% to about 95%. Over the same period, rates of central line–associated bloodstream infections and ventilator-associated pneumonia both declined by more than 40%.

Despite extensive research, handoffs remain a leading concern in patient safety. This study examined handoffs from the emergency department to the inpatient unit, a transition known to be associated with adverse events. Investigators analyzed handoff communications before and after implementation of The Joint Commission's Targeted Solutions Tool, an online application to improve handoff communication, which includes the needed interventions and change management strategies to implement them. The rate of defective handoffs declined significantly after implementation of the tool. However, even after implementing the Targeted Solutions Tool approximately 12% of examined handoffs were defective, highlighting the challenge of achieving a zero error rate in patient safety.

Professionalism in medicine is considered an essential component of safety culture, but efforts to monitor and address disruptive behaviors among physicians have not produced the desired outcomes. This commentary discusses the need for more explicit emphasis on building physician skills and attitudes to support zero harm, process improvement, high reliability, and commitment to excellence in all areas of medical care.

Although appropriate handwashing has been identified as an essential factor in preventing health care–associated infections, hand hygiene rates remain unacceptably low at many hospitals. This quality improvement project aimed to achieve adherence to hand hygiene practices at eight hospitals using change management methods drawn from human factors engineering. Each hospital investigated and identified specific causes of noncompliance with handwashing and developed specific interventions to address these barriers. These individualized efforts yielded a significant improvement in handwashing behavior. The authors argue that allowing each site to tailor the intervention to the specific causes of noncompliance led to the sustained improvements. This study suggests that local improvement may be a fruitful method to enhance the proven but incompletely implemented practice of hand hygiene. A recent AHRQ WebM&M interview and perspective discuss ways to enhance hand hygiene adherence.

… frustrating. This commentary, by patient safety expert Dr. Mark Chassin, recommends that health care shift its focus from … safety movement. A prior AHRQ WebM&M interview with Dr. Chassin discussed the role of the Joint Commission in …

… toward high reliability. The article's lead author, Dr. Mark Chassin, was interviewed for AHRQ WebM&M in 2009. …

Accreditation by The Joint Commission was associated with stronger performance on disease-specific measures of hospital quality of care. Accredited hospitals also appeared to achieve greater improvements in care over time compared to non-accredited hospitals.

Reviewing progress in quality improvement, this commentary offers a framework to guide health care organizations toward high reliability.

… adverse consequences . Under the leadership of Dr. Mark Chassin, The Joint Commission has taken an increasingly …

This case study describes the events of a patient who underwent an unintended invasive cardiac electrophysiology study. While reviewing the details of the case and the institution’s root cause analysis, the authors identify 17 distinct errors that culminated in the procedure taking place. The authors discuss the role of the individual versus the system, the existing culture contributing to the error, and strategies to avoid similar errors in the future. This article is part of a special collection entitled “Quality Grand Rounds,” a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.