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To Err Is Human broke the silence around patient safety, bringing awareness to the 98 000 preventable deaths per year caused by medical error in hospitals.1 Instead of asserting that these deaths were due to bad people working in health care, however, it provided a clear explanation that bad systems were to blame and needed to be made safer. In its wake, efforts to create a culture of patient safety emerged, using systems-based interventions to target multiple issues surrounding diagnostic errors, procedural events, health care–associated infections, and medication management. Antibiotic resistance and misuse are patient-safety issues, too. In response to rising antibiotic resistance and the dangerous consequences of antibiotic overuse and misuse, hospitals have adopted a culture of patient safety around antibiotic use through implementation of antibiotic stewardship programs. Of course, antibiotic resistance is not just a threat in hospitals. Nursing homes are sites of high and frequently inappropriate antibiotic prescribing.2 Nursing home residents, with recurrent health care exposure and antibiotic use, frequently harbor antibiotic-resistant organisms. The number of nursing homes engaging in various antibiotic stewardship activities has grown in recent years.3 However, antibiotic stewardship programs remain immature in most facilities and identifying approaches to accelerate the growth of stewardship operations in nursing homes is a critical need. Drawing from the experiences and resources of antibiotic stewardship in the hospital setting, Katz et al4 leveraged the existing “AHRQ Acute Care Hospital Toolkit to Improve Antibiotic Use” to create a 12-month education-based intervention adapted to the nursing home setting. The intervention took a patient safety approach and emphasized the importance of improved teamwork, clinical best practices, and the science of safety to encourage nursing facilities to expand their stewardship activities and impact. The educational bundle was delivered through webinars, posters, pocket cards, and virtual office hours with experts. It even cleverly rebranded the “Four Moments of Antibiotic Decision Making” framework for long-term care.4 To assess the outcomes of this intervention, Katz et al4 compared key aspects of antibiotic utilization and antibiotic-related outcomes collected during the first 2 months of the 12-month intervention with the final 2 months of the study period. Overall changes in antibiotic use, urine cultures, and positive tests for Clostridioides difficile observed in this study were modest. During the last 2 months of the intervention, antibiotic starts per 1000 resident-days decreased by 0.41 from a baseline of 7.9 (0.41/7.9 = 0.052), and antibiotic days of therapy per 1000 resident-days decreased by 3.1 from a baseline of 64.1 days (3.1/64.1 = 0.048); thus, both measures decreased by approximately 5% compared with baseline values. The number of urine cultures collected during the last 2 months of the intervention was nearly 13% lower compared with the baseline period. While rates of positive tests for C difficile during the last 2 months of intervention were 10% lower than during the baseline period, this difference was not significant. While the study by Katz et al4 is unquestionably the largest study of a nursing home antibiotic stewardship intervention ever conducted in the US, the study design and analytical approach make it difficult to ascertain a causal relationship between the intervention and observed outcomes. In the absence of a concurrent control group, it is impossible to exclude the possibility of secular influences on the changes in antibiotic utilization observed in study nursing homes. Outpatient fluoroquinolone prescriptions in the US have dropped 42% from 2015 to 2019.5 While it is debatable whether outpatient prescribing patterns can be applied to the long-term care setting, it is notable that much of the observed change in antibiotic utilization in this study was associated with reductions in + Related article