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Journal Article > Commentary
Spear SJ. Harv Bus Rev. September 2005;83:78-91.
This commentary provides a broad overview of the issues facing health care systems in their efforts to promote quality and safety. The author discusses pervasive cultural barriers and process limitations that contribute to errors, while providing a series of anecdotes to demonstrate how easy and frequent these events can occur. Approaches for improvement that draw from the experiences of non-health care organizations, such as Toyota, are included. The strength of the commentary lies in the compelling stories shared and the perspectives offered to foster change.
Journal Article > Study
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.
Catheter-related bloodstream infections (CRBSI) remain a common and deadly patient safety issue in intensive care units (ICUs), although prior research has defined several effective preventive strategies. In the ''Keystone ICU'' project, funded by the Agency for Healthcare Research and Quality (AHRQ), 103 ICUs in Michigan participated in a statewide safety initiative, including instituting five evidence-based preventive strategies recommended by the Centers for Disease Control and Prevention (CDC). The project focused on changing provider behavior through addressing safety culture, incorporating a centralized education program for team leaders at each institution, and closely collaborating with infection control personnel. The intervention was remarkably successful, nearly eliminating CRBSI entirely in most ICUs over an 18-month follow-up period. A related editorial lauds the success of the intervention and calls for all U.S. hospitals to adopt similar programs.