Search results for "Education and Training"

Quality and value have intersecting influence on the safety of health care. Articles in this special issue explore key principles of safe orthopedic care for both adult and pediatric patients. Topics covered include leadership's role in implementing sustainable improvement, postsurgery patient education as a safety tactic, and the impact of surgical volume on safe, high-quality care.

Leadership commitment to improvement efforts is key to sustain patient safety initiatives. This toolkit consists of a workbook, board engagement self-assessment tool, and video modules to help leadership translate efforts from the board room to the front line to reduce medical errors in their hospitals.

Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.

A key activity in patient safety work involves drawing from institutional memory to understand failures and design interventions to prevent them from reoccurring. This commentary discusses learning from failure, or remembrance, in health care and suggests avenues for future research to increase its application in improvement efforts.

Program infrastructure that incorporates the knowledge of staff at executive and unit levels can enable system improvements to be sustained over time. This commentary describes how an academic medical center integrated departmental needs with overarching organizational concerns to inform safety and quality improvement work. The authors highlight the need for flexibility and structure to ensure success.

The outpatient setting is receiving increased attention as a research focus in patient safety. This bibliography provides an annotated list of articles summarizing safety improvement efforts in the ambulatory setting. Topics explored include safety culture, measurement, team training, test result management, incident reporting, and diagnostic error.

Hospital-acquired pressure ulcers are considered a never event and can result in loss of payment to hospitals. In this study, researchers surveyed chief nursing officers across Veterans Health Administration acute care hospitals to better understand how organizational strategies are operationalized with regard to implementing pressure ulcer prevention programs. They found that such strategies were not operationalized in a uniform manner across the hospitals and that nurse leadership played a substantial role in influencing the implementation of pressure ulcer prevention initiatives.

High reliability has been recently adopted as a goal for health care. This book reviews the primary elements of high reliability organizations and describes how hospitals can apply these concepts to enhance health care safety. The author also underscores the importance of leadership commitment to ensure success.

Improper injection practices associated with point-of-care testing and treatment can contribute to the spread of health care–associated infections. This position paper outlines how clinicians and infection preventionists can reduce unsafe behaviors with surveillance, oversight, enforcement, individual skills development, and professional accountability.

A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.

Opioids are high-risk medications that are increasingly problematic for patients and providers. This guide provides instructions to help hospitals implement initiatives to improve safe prescribing and administration of opioids. Highlighted recommendations include strategies to assess processes, identify best practices, and engage staff to reduce adverse events involving opioids.

Involving trainees in patient safety work can ground their development in quality improvement. This commentary discusses a three-level framework to engage trainees in quality improvement and patient safety work. The authors review insights regarding strengths and weaknesses of each level of the model and use scenarios to illustrate its use in hospitals.

Enabling clinicians and management to access data can help them uncover weaknesses in practice, determine performance measures, and drive improvements. This commentary introduces a series of upcoming articles that will explore information derived from the Society of Thoracic Surgeons National Database to aid in understanding patient safety hazards in cardiothoracic surgery.

Committed leadership is essential to enhance organizational safety. Drawing from previous recommendations to generate lasting improvements in response to the Francis inquiry, this report discusses a model that focuses on learning, influencing, resilience, creativity, and systems thinking to help clinicians frame discussions about improving quality and safety in health care.

This initiative provides information on surgical fires and makes recommendations to address the risk of fires during surgery.

To address the lack of standards on intravenous (IV) push medication administration, this guidance reflects applied expert opinion and current evidence regarding IV push medication administration to support application of best practices to facilitate safe care. To ensure the applicability and use of the recommendations in hospitals, the authors sought broader consensus and review from the field.

This Web site highlights the work of a United Kingdom initiative launched in 2008 to apply safety improvement tactics from high-risk industries to care services. The program engages teams to identify problems in care delivery, develop innovations, and then test and evaluate the new approaches. The site provides access to project reports, overall guidance, and analysis of what was learned.

The comprehensive unit-based safety program (CUSP), originally developed by Dr. Peter Pronovost and others at Johns Hopkins, has been shown to improve safety culture in multiple clinical settings. This commentary describes the development of a quality improvement collaborative designed to facilitate the implementation of CUSP in a group of academic and community hospitals. In addition to discussing the mentorship and network learning aspects of the collaborative, the authors also provide detailed descriptions of the implementation process and barriers faced at each institution. A prior article explored the role of quality improvement collaboratives in enhancing safety. Dr. Pronovost talked about his work with checklists and the science of improving patient safety in a past AHRQ WebM&M interview.

Change management has been promoted as a strategy to implement improvements in clinical settings. This commentary discusses the complexity around introducing change in health care and suggests that change management, systems thinking, and employee engagement are elements of successful quality improvement initiatives.

This article discusses Kaiser Permanente's efforts to develop a performance improvement system and become a learning organization.

This article discusses incidents involving misadministration of IV insulin and makes recommendations to improve safety in delivering this high-alert medication.

This report summarizes progress in patient safety improvement in the past decade and reviews the 2017 activities of the Patient Safety Authority, including an update on efforts to standardize their reporting processes and to reduce health care–associated infections in nursing homes. The report also summarizes the new 5-year strategic plan for the agency that explicitly emphasizes a focus on improving diagnosis.

Brent C. James, MD, MStat, is Chief Quality Officer and Executive Director of the Institute for Health Care Delivery Research at Intermountain Healthcare.

A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.

Health care in the United States is undergoing profound changes due to societal demands to improve the quality of care and simultaneously reduce costs.

Geri Amori, PhD, is Vice President for the Education Center at The Risk Management and Patient Safety Institute, and a popular writer and speaker.

This commentary outlines an educational program for nursing students designed to prepare them for involvement in quality improvement work.

Staff education—particularly for physicians—and more efficient reporting systems were associated with increased usage of incident reporting systems in this Japanese study.

This video series uses two real cases of patients who died due to preventable errors after elective surgery to illustrate fundamental concepts in patient safety and provide lessons for patients and families in engaging in their own care. The circumstances leading to the death of Lewis Blackman, one of the patients discussed in this video series, are discussed in more detail in a separate article that analyzes his death as an example of failure to rescue.

Discussion of adverse events in morbidity and mortality (M&M) conferences serves as an important tool for both educational and quality improvement initiatives. This study found that 80% of cases reviewed in monthly psychiatry M&M conferences at a children's hospital provided opportunities for patient care improvement.

This article charts one health system's efforts to create a culture of safety through leadership development initiatives in 32 hospitals.

This survey explores the varied roles that medical librarians play in searching for and disseminating information on patient safety. The majority of librarians surveyed had actively participated in patient safety initiatives.

This Web site includes a toolkit, posters, and educational materials to support safe tube feedings and prevent tubing misconnections. 

This study developed and implemented an educational program that provided prescribing standards, formal education, and repeated feedback to reduce errors in practice.

The 115 articles freely available in this latest issue of AHRQ's Advances in Patient Safety represent the state of the art in patient safety. Serving as an update and extension to the prior volume, the articles are grouped into four major content areas—assessment, culture and redesign, performance and tools, and technology and medication safety—and are freely available online through the link below.

This article describes common problems associated with insulin pen injectors and provides recommendations for their safe use.

Atul Gawande, MD, MA, MPH, Associate Professor of Surgery at Harvard Medical School and the Harvard School of Public Health, is an accomplished surgeon and writer and is the recipient of a 2006 MacArthur Fellowship. He is an active clinician at Brigham and Women's Hospital and the Dana Farber Cancer Institute. Dr. Gawande has written two acclaimed and best-selling books: Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. A staff writer for the New Yorker, he also recently completed a stint as a guest columnist for the New York Times. Dr. Gawande is leading the World Health Organization's Second Global Patient Safety Challenge: "Safe Surgery Saves Lives." We asked him to speak with us about professionalism, training, patient safety, and the writing process.

This publication shares news related to the World Health Organization's Global Patient Safety Challenge.

This report shares successful patient safety strategies employed in Ontario hospitals to address medication safety, patient incident management, infection issues, and administrative process improvements.

This Web site offers news articles, event listings, and information on minimizing health care-associated infections for both professional and lay audiences.

This special issue includes numerous articles reviewing the activities and successes of the patient safety movement outside the United States.

This Web site includes patient safety-related materials for orthopedic surgeons such as checklists, educational modules, tips, and American Academy of Orthopaedic Surgeons (AAOS) official statements.

This Web site provides information on the multidisciplinary safety team at Johns Hopkins University, including research projects, presentations, and useful tools for patients, families, and practitioners.

With 4 volumes and 140 articles (all of which are freely available through the link below), this expansive collection of literature illustrates the progress made since the 1999 Institute of Medicine's report, To Err is Human: Building a Safer Health System. The efforts represent a successful collaboration between the Agency for Healthcare Research and Quality and the Department of Defense-Health Affairs in meeting the challenge of improving patient safety knowledge, research, and implementation.

Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications.

This review discusses medication errors and patient safety in the context of geriatrics and offers recommendations to improve safety for elderly patients.

This conference will feature sessions presenting tools and practices that help all health care settings move forward in their patient safety work with an emphasis on creating environments that support psychological safety. Featured speakers include Dr. Jo Shapiro. The event will also recognize exemplars from Oregon's Patient Safety Reporting Program.

Most safety improvement efforts justifiably emphasize system performance. A clinician's individual skill level is an important component of the care delivery system that can influence patient safety—both independently and in conjunction with other system components. Emerging evidence examines assessment, monitoring, and improvement of clinicians' competence as a means of addressing this unique component and ensuring patient safety.

Hospitalized in the ICU with hypoxic respiratory failure due to community-acquired pneumonia, an elderly man had increased pulmonary secretions on hospital day 2 for which the critical care provider decided to perform bedside bronchoscopy. Following the procedure, the patient was difficult to arouse, nearly apneic, and required intubation. The care team paused and discovered that after the patient had received 2 mg of intravenous midalozam, his IV line had been flushed with an additional 10 mg of the benzodiazepine, rather than the intended normal saline. This high dose of midazolam led to the respiratory failure requiring intubation. On top of that, instead of normal saline, lidocaine had been used for the lung lavage.

The role of hospital boards in influencing and financing efforts to improve safety is of recognized importance. However, leaders must have the skills and mindset needed to understand and perform quality governance responsibilities. This report provides a framework drawn from the Institute of Medicine six elements of quality to clarify responsibilities of trustees and health system leaders with regard to quality oversight.

Patient and family engagement can enhance both individual safety and organizational improvement efforts. This position paper advocates for patients and families to be active partners in all aspects of their care, treated with respect and dignity, engaged in improving health care systems, and directly involved in education of health care professionals. The piece also provides strategies to employ these recommendations in the daily practice.

The Kentucky Institute for Patient Safety and Quality offers the support of a patient safety organization and educational opportunities to foster safety and quality improvement throughout the state. Services provided include Safe Table events, data analysis, and peer review consultations.

Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.

Errors in the administration of intravenous medications can result in patient harm. This set of articles discusses the results of a nationwide IV push medication survey. The first article reviews unsafe practices in care delivery as defined by inpatient clinicians. The second article recommends ways to improve practice such as assessment of current practices, use of prefilled syringes, and heightened attention to effective labeling.

Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.

Mobile health care applications are increasingly being developed and marketed to patients for self-care and diagnosis, with little oversight as to their effectiveness or safety. This commentary outlines four key issues that must be addressed to improve the safety of medical applications.

Incorporating patient safety content into the demanding schedule of medical school education is challenging. This commentary describes the design and implementation of an embedded patient safety and quality improvement learning opportunity. The approach used a retained surgical sponge simulation during an anatomy course to illustrate how errors can occur, affect the patient, and be prevented. A PSNet perspective explored the value of simulation as an educational technique.

The National Health Service (NHS) is a global leader in patient safety improvement. This report reviews the results of a study that explored whether staff had access to information needed to prevent errors. Clinicians in four acute NHS hospitals were surveyed to assess how information is used by nurses, staff, and senior hospital managers. The report concluded that robust access to patient information improved care and proactive risk management activities.

Medication administration errors are common and costly, especially for children. Investigators conducted a multipronged quality improvement intervention for pediatric medication administration. First, they implemented a one-time simulation training for pediatric bedside nurses across emergency department, hospital ward, and intensive care settings to foster use of standardized medication administration best practices. They observed bedside nursing via audits for 18 months of follow-up. Adherence to best practices improved from 51% of medication administration instances to 84%, and the rate of medication administration errors declined significantly. The authors suggest that simulation training is an effective strategy to improve the safety of pediatric medication administration.

There is increased emphasis on incorporating quality and patient safety improvement experiences into medical curricula. This commentary states the case for integrating problem analysis, intervention prioritization, and individual practice assessment opportunities into gastroenterology fellowship activities. The authors describe their multimodal educational approach and provide examples of fellow-led projects initiated during the program.

This analysis of specialty-specific milestones for graduate medical education found that about 40% mentioned patient safety or quality improvement. Emphasis on patient safety and quality improvement skills varied by specialty. The authors conclude that patient safety concepts are addressed in graduate medical education competencies.

The National Health Service (NHS) is a global leader in patient safety improvement. This website coalesces information and activities generated by three NHS improvement efforts: patient compensation, performance assessment, and fair resolution of appeals between the NHS and primary care contractors.

This prospective cohort study found that many outpatients treated at a chronic pain clinic were willing to voluntarily taper opioid medications. Although nearly 40% of patients dropped out of the study, those that remained significantly reduced their opioid dosing. The authors suggest that offering a voluntary gradual opioid taper to patients with chronic pain may reduce their opioid dose.

Skills in studying, designing, implementing, and measuring improvement initiatives are necessary to ensure broad transfer of innovations. Articles in this special issue offer insights from an international consensus-building session that explored methods of creating actionable information from health care improvement work. In the editorial, the authors suggest that guidance is needed to help investigators to enhance the rigor and transferability of results to support systemwide learning and improvement.

Learning collaboratives are multimodal interventions that are often used to implement evidence-based practices. This perspective from AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type of positive change; communication among members; duration and sustainability; and social systems, or the organization and culture of the collaborative. The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions employ this taxonomy.

Implementing patient safety curricula can be challenging. This commentary describes one organization's project to incorporate patient safety and quality improvement content into a larger educational effort involving residents and faculty as learners.

Surgical fires have the potential to cause considerable patient harm. This commentary traces the history and experience of an educational strategy to improve safety of surgical energy device use. The program utilizes strategies such as certification, online curricula, and mandated education to engage the surgical team in skill enhancement. The authors describe an international example to illustrate how this approach can be implemented to augment surgical patient safety.

Dr. Bilimoria is the Director of the Surgical Outcomes and Quality Improvement Center of Northwestern University, which focuses on national, regional, and local quality improvement research and practical initiatives. He is also the Director of the Illinois Surgical Quality Improvement Collaborative and a Faculty Scholar at the American College of Surgeons. In the second part of a two-part interview (the earlier one concerned residency duty hours), we spoke with him about quality and safety in surgery.

Residents rarely receive feedback from patients and families during training, which may represent a missed opportunity to improve their communication and patient care skills. This commentary recognizes this gap and suggests tactics to incorporate feedback into residency programs, such as the use of structured collection formats and neutral information sharing processes.

This project report describes how an academic health system utilized a modified Lean framework to uncover weaknesses in reporting processes for student mistreatment. The authors found that reporting was hindered by lack of student awareness regarding reporting mechanisms and perceptions that no action would result from reporting mistreatment. The authors outline recommendations to address these challenges.

The opioid epidemic is a challenge to patient safety and public health. This report reviews tools to help health care systems target eight areas of focus that have potential to reduce the impact of opioid misuse, including improving prescribing practices, collaborating with communities, and educating patients.

Although patient safety education efforts are in place across health care, approaches to evaluating the effectiveness of such programs are needed. This article describes an approach developed by the Department of Veterans Affairs to assess their resident patient safety leadership development program.

Residency programs face barriers to incorporating patient safety and quality improvement learning opportunities into their curriculum. This commentary discusses how to address these challenges in subspecialty training and enhance the experience of trainees in safety and quality skill development.

Improving antibiotic use is a strategy to reduce dangerous health care–associated infections. This website provides information associated with a large-scale improvement initiative. This project will use the Comprehensive Unit-based Safety Program improvement strategy to develop and test a bundle of interventions in the ambulatory care, long-term care, and acute care environments. Applications for long-term care facilities to participate are currently being accepted.

Engaging clinicians and hospital staff is important for sustainable quality and safety improvement. This commentary describes a program to enhance staff involvement by providing education in risk identification, process assessment, project management, and patient engagement.

Technical and psychological factors can affect adverse event reporting. This quality improvement report highlights an effort to enhance resident reporting in an emergency department. Residents were educated about incident reporting and participated in feedback sessions every 2 months to improve their familiarity with the reporting system as well as augment their knowledge regarding how and what should be reported. The number and quality of reports increased following the intervention.

This commentary highlights the importance of engaging residents in root cause analysis of errors and near misses. The authors discuss how participation in root cause analysis can educate trainees about process analysis and augment skill development.

Contextual errors can occur when health care providers fail to consider a patient's individual context, such as limited literacy, when making a treatment plan. This qualitative study of clinicians identified 12 types of contextual errors that can impede patient self-management and lead to harm. The authors advocate a "contextual differential" to consider these potential errors.

Patient engagement in the process of care is important to improve safety in primary care. This guide includes case studies and highlights handoffs, teach-back, tools to prepare patients for appointments, and brown-bag medication management as strategies to encourage patients and caregivers to participate in safety.

This commentary describes how one hospital established a resident leader to embed quality improvement and patient safety education into daily care processes. The authors review strategies the resident leader championed to drive improvement, including quarterly hospital-wide morbidity and mortality conferences, mock root cause analyses, and a feedback mechanism to respond to resident concerns.

Despite widespread implementation of incident reporting systems, events remain underreported by physicians. This quality improvement study increased the proportion of incident reports submitted by physicians using text message prompts, faculty development, and a patient safety rotation for medical resident physicians. These results demonstrate that specific interventions can increase physician use of voluntary event reporting systems.

Medication administration errors have been studied primarily in the hospital environment. Less is known about the types of errors that may occur in the home setting and the role caregivers play in this context. This narrative systematic review found caregiver medication administration error rates ranging from 1.9% to 33% of all medications administered, highlighting a potential threat to patient safety.

Prior research has shown that reducing preventable perinatal harm leads to a decrease in malpractice claims. In this prospective study involving the perinatal units across 14 hospitals from 12 states and accounting for almost 350,000 deliveries, researchers found that successful implementation of 3 standard care processes resulted in a 14% decrease in harm in perinatal care from the baseline period.

This quality improvement project sought to prevent harmful or unnecessary care through a combination of electronic health record alerts and provider education. Three of five completed projects undertaken demonstrated success in reducing the unneeded intervention: fewer serum creatinine tests ordered in those with end stage renal disease, fewer portable chest radiographs ordered in the intensive care unit, and fewer bone-density scans ordered in average-risk women under age 65. The authors cite leadership support, frontline clinician engagement, and inclusion of trainees as factors that contributed to success of their interventions.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.

Substantial progress has been made in improving health care safety, but more work is needed to optimize those efforts. Advocating for the development of an infrastructure that supports safety improvement, this editorial suggests that performance measures, initiative coordination, and recognition of local successes are ways to advance patient safety.

Launched in 2006, the Indiana Patient Safety Center (IPSC) is dedicated to promoting safety culture and reliable systems of care in the state. This website provides resources related to IPSC educational activities and efforts to raise awareness of local and national safety initiatives, including the Hospital Engagement Network.

Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

Although duty hour restrictions were enacted to improve patient safety, evidence regarding their impact has been mixed. This focus group study examined resident perceptions of quality of life and patient safety before and after implementation of a reduced duty hours model. Participants reported less fatigue but also expressed concern about the greater number of handoffs, echoing the ongoing duty-hours debate discussed in a recent PSNet perspective.

Development of high reliability remains an elusive goal for health care organizations. The Joint Commission has also advocated for achieving high reliability in health care. This website collects evidence and existing tools to help organizations work toward high reliability, including the ORO 2.0 assessment tool to enable hospital leaders evaluate their culture, leadership, and performance.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

Audit and feedback are key patient safety strategies. This combined simulation and pre–post implementation study found that staff-reported intentions to improve practice increased after receiving feedback. However, nearly half did not compare their own performance to available benchmarks.

Disruptive behavior is common in health care settings. This commentary discusses the development and implementation of a multifaceted initiative to address unprofessional conduct among nurses. The authors highlight the importance of involving the organization, leaders, and individuals in achieving culture change.

Morbidity and mortality conferences are a time-tested educational strategy for patient safety. This study demonstrates that using a structured tool to facilitate systems-based learning resulted in increased resident engagement in quality improvement practices. The results demonstrate the benefits of widespread implementation of system-based morbidity and mortality conferences.

This systematic review explored interventions to augment diagnostic reasoning among physicians. Cognitive forcing and guided reflection were two strategies that consistently improved cognition. This finding suggests that these methods should be more widely implemented to enhance timely and accurate diagnosis.

The AHA-McKesson Quest for Quality Prize winners are recognized for commitment to the goals outlined in Crossing the Quality Chasm. These webinars shared insights from health care organizations that received recognition in 2015 for implementing programs to form partnerships with patients, families, and their communities to generate improvements in health care and eliminate harm.

Checklists have been highlighted as useful tools for nurses and physicians to improve communication and reduce care omissions. This commentary describes the development of a customizable checklist template designed to enable patients to engage in their care and safety.

There is a recognized need for patient safety content in medical school curricula. This commentary describes the development, implementation, and evaluation of a program that integrated quality and safety improvement concepts into an existing 3-year curriculum. A patient safety expert worked with faculty to recommend the content and goals of the pathway. Students reported positive reactions to the program.

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.