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%.

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.

This commentary describes a World Health Organization effort to design and apply standardized care processes to address safety concerns. Three standards (surgical site identification, medication reconciliation, and concentrated injectable medicines) have been developed and implemented in multiple countries in the past 5 years.

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

… 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.

Voluntary error reporting systems are perhaps the most controversial of the available tools for detecting patient safety incidents. A sizable body of research has characterized the limitations of such systems, but they remain a cornerstone of safety efforts at many institutions. This consensus conference, sponsored by the World Alliance for Patient Safety, drew together an international group of error reporting experts in order to develop a learning community for incident reporting. The ultimate goal was to develop guidelines for effective use of reporting systems to improve safety. Discussing the advantages and challenges of current reporting systems, this article proposes guidelines for maximizing incident reporting utility (based on a previously published framework). A previous article discussed the use of different types of reporting systems to obtain a comprehensive view of patient safety within an institution.

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

Since the landmark IOM report on medical errors, the field of patient safety has frequently relied on the aviation industry as a source of learning to prevent accidents and harm in health care. This commentary explores these learnings further by highlighting the success of the Commercial Aviation Safety Team (CAST), a public–private enterprise voluntarily established by the aviation industry and the government in the mid-1990s. The authors, led by a pioneer in the patient safety field, propose a similar partnership in the health care community to coordinate a national agenda in improving the quality and safety of care. They call the proposed organization the Public Private Partnership to Promote Patient Safety (P5S), and provide a model for its success.

Language barriers likely impair patients' ability to receive quality health care, but the link between limited English proficiency (LEP) and patient safety has not been extensively researched. This study examined voluntary reports of adverse events reported at six hospitals and found that adverse events were more common in patients with LEP. Events in patients with LEP were frequently attributable to communication problems and were more likely to result in patient harm. Though the study only examined voluntarily reported incidents, it adds to prior research identifying LEP as a potential contributor to adverse events.

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.

The rapid increase in research and publications on patient safety following the landmark Institute of Medicine report resulted in the need for a common set of definitions and terminology for patient safety concepts.  To achieve this goal, the authors developed a taxonomy based on a systematic literature review.  The taxonomy, which has been widely accepted since its publication, consists of 5 primary classifications that can be used to classify an error:  impact, type, domain, cause, and prevention or mitigation.