The Top Patient Safety Strategies That Can Be Encouraged for Adoption Now
Authors: Paul G. Shekelle, Peter J. Pronovost, Robert M. Wachter, Kathryn M. McDonald, Karen Schoelles, Sydney M. Dy, Kaveh Shojania, James T. Reston, Alyce S. Adams, Peter B. Angood, David W. Bates, Leonard Bickman, Pascale Carayon, Liam Donaldson, Naihua Duan, Donna O. Farley, Trisha Greenhalgh, John L. Haughom, Eileen Lake, Richard Lilford, Kathleen N. Lohr, Gregg S. Meyer, Marlene R. Miller, Duncan V. Neuhauser, Gery Ryan, Sanjay Saint, Stephen M. Shortell, David P. Stevens, Kieran Walshe
Journal: Annals of Internal Medicine (2013)

Making Health Care Safer: A Critical Review of Evidence Supporting Strategies to Improve Patient Safety5 March 2013The Top Patient Safety Strategies That Can Be Encouraged for Adoption NowFREEPaul G. Shekelle, MD, PhD, Peter J. Pronovost, MD, PhD, Robert M. Wachter, MD, Kathryn M. McDonald, MM, Karen Schoelles, MD, SM, Sydney M. Dy, MD, MSc, Kaveh Shojania, MD, James T. Reston, PhD, MPH, Alyce S. Adams, PhD, Peter B. Angood, MD, David W. Bates, MD, MSc, Leonard Bickman, PhD, Pascale Carayon, PhD, Liam Donaldson, MBChB, MSc, MD, Naihua Duan, PhD, Donna O. Farley, PhD, MPH, Trisha Greenhalgh, BM BCH, John L. Haughom, MD, Eileen Lake, PhD, RN, Richard Lilford, PhD, Kathleen N. Lohr, PhD, MA, MPhil, Gregg S. Meyer, MD, MSc, Marlene R. Miller, MD, MSc, Duncan V. Neuhauser, PhD, MBA, MHA, Gery Ryan, PhD, Sanjay Saint, MD, MPH, Stephen M. Shortell, PhD, MPH, MBA, David P. Stevens, MD, and Kieran Walshe, PhDPaul G. Shekelle, MD, PhDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Peter J. Pronovost, MD, PhDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Robert M. Wachter, MDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Kathryn M. McDonald, MMFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Karen Schoelles, MD, SMFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Sydney M. Dy, MD, MScFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Kaveh Shojania, MDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, James T. Reston, PhD, MPHFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Alyce S. Adams, PhDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Peter B. Angood, MDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, David W. Bates, MD, MScFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Leonard Bickman, PhDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Pascale Carayon, PhDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Liam Donaldson, MBChB, MSc, MDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Naihua Duan, PhDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Donna O. Farley, PhD, MPHFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, Trisha Greenhalgh, BM BCHFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Veterans Affairs Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan.Search for more papers by this author, John L. Haughom, MDFrom the RAND Corporation, Santa Monica, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, University of California, San Francisco, San Francisco, Stanford Center for Health Policy and Center for Primary Care and Outcomes Research, Stanford, Kaiser Permanente, Oakland, and University of California, Berkeley, Berkeley, California; Johns Hopkins Medicine Patient Safety and Quality, Johns Hopkins University, and John's Hopkins Children's Center, Baltimore, Maryland; ECRI Institute, Plymouth Meeting, RAND Corporation, Pittsburgh, and University of Pennsylvania, Philadelphia, Pennsylvania; Centre for Patient Safety, University of Toronto, Ottawa, Ontario, Canada; National Quality Forum, Washington, DC; Harvard University, Brigham and Women's Hospital, Boston, Massachusetts; Vanderbilt University's Peabody College, Nashville, Tennessee; University of Wisconsin-Madison, Madison, Wisconsin; Imperial College London and Queen Mary, University of London, London, University of Birmingham, Edgbaston, Birmingham, and Manchester Business School, University of Manchester, Manchester, United Kingdom; New York State Psychiatric Institute, New York, New York; PeaceHealth Medical Group, Eugene, Oregon; Research Triangle Institute International, Research Triangle Park, North Carolina; Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, North Hampshire; Case Western Reserve University, Cleveland, Ohio; and Ve