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Classics and Emerging Classics

To help our readers navigate the tremendous breadth of the PSNet Collection, AHRQ PSNet editors and advisors have given the designation of “Classic” to review articles, empirical studies, government and stakeholder reports, commentaries, and books of lasting importance to the patient safety field. These items have the potential to impact how providers approach care practice and are regularly referenced in the literature. More information on the selection process.

 

The “Emerging Classics” designation identifies those resources that may not have met the level of a “Classic” yet due to limited citation in the published literature or in the level of impact/contribution to the environment, but these are resources which our patient safety subject matter experts believe have the potential to drive change in the field.

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All Classics and Emerging Classics (1066)

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Displaying 1 - 20 of 1066 Results
Displaying 1 - 20 of 1066 Results
Measurement Tool/Indicator
Classic
Rockville MD: Agency for Healthcare Research and Quality; 2020.
Culture has been described as a key to establishing high reliability organizations. The National Quality Forum's Safe Practices for Healthcare and the Leapfrog Group both mandate hospitals to regularly assess their safety culture. This AHRQ Web site provides validated safety culture survey tools (Hospital, Medical Office, Nursing Home, Community Pharmacy, Ambulatory Surgery Center), user guides health care organizations can use to implement the surveys and a bibliography of articles discussing the use of SOPS in the field. Organizations can also use the AHRQ database to compare their Surveys on Patient Safety Culture™ (SOPS®) results. In addition, reports are available that summarize the benchmarking data across cohorts nationwide. An AHRQ WebM&M perspective discussed how to establish a safety culture. The 2024 Hospital Survey data collection period is now closed.
Measurement Tool/Indicator
Classic
Agency for Healthcare Research and Quality
The AHRQ Patient Safety Indicators (PSIs) represent quality measures that make use of a hospital's available administrative data. The PSIs reflect the quality of inpatient care but also focus on preventable complications and iatrogenic events. Investigators have found PSIs to be a useful tool for understanding adverse events and identifying possible areas of improvement within health care delivery systems. Although relying on administrative data has clear limitations, select PSIs have been shown to accurately identify certain accidental inpatient injuries. The AHRQ Web site offers publicly available comparative data, along with resources and tools. Patient safety measurement methods are discussed in an AHRQ WebM&M perspective. Originally released in 2005, the PSI were most recently updated in August 2023.
Fact Sheet/FAQs
Classic
Horsham, PA; Institute for Safe Medication Practices: July 2023.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
Department of Health and Human Services, Agency for Healthcare Research and Quality, Department of Defense.
Effective teamwork plays an essential role in providing safe patient care. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed inititally in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. The 3.0 version of the widely implemented program is organized around 5 key strategies: patient focus, integrated platform, modular course design, active adult learning and emergent team challenges and opportunities. It provides new tools to measure its impact, supports increased emphasis on the role of patients in teams, and includes a new pocket guide. A PSNet WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented a missed diagnosis of sepsis that lead to the death of a patient.
Nutbeam D, Lloyd JE. Annu Rev Public Health. 2021;42:159-173.
Health literacy is a social determinant of health and can affect the ways people understand and interact with the health system. This review describes categories of health literacy, how it functions as a social determinant of health, and interventions to improve health literacy at system, community, and individual levels.
Trockel MT, Menon NK, Rowe SG, et al. JAMA Netw Open. 2020;3:e2028111.
Fatigue among health care workers can increase the risk of errors. This large cross-sectional study of attending and house staff physicians found that sleep-related impairment was associated with increased burnout, decreased professional fulfillment, and increased self-reported clinically significant medical error. Organizational policies should focus on reducing sleep-related impairment in order to reduce harm to patients and physicians.
Sjoding MW, Dickson RP, Iwashyna TJ, et al. N Engl J Med. 2020;383:2477-2478.
Pulse oximetry is used to triage patients, initiate or adjust oxygen administration, and, more recently, as a way to remotely monitor COVID-19 patients at home. However, a study in the Johns Hopkins Health System showed that Asian, Black, or Hispanic patients are more likely to experience inaccurate readings, potentially resulting in missed or delayed diagnosis of respiratory diseases. This study used paired oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas in Black and white patients before and during the COVID-19 pandemic. Consistent with the Johns Hopkins study, Black patients had three times the frequency of occult hypoxia than white patients.
Han SM, Greenfield G, Majeed A, et al. J Med Internet Res. 2020;22:e23482.
Social distancing precautions due to the COVID-19 pandemic have led to increased use of telehealth. The authors of this systematic review conclude that there is insufficient evidence to determine whether remote prescribing in primary care changes antibiotic prescribing practices. Future research should further assess remote prescribing to ensure there are no negative impacts on antimicrobial stewardship.  
Gates PJ, Hardie R-A, Raban MZ, et al. J Am Med Inform Assoc. 2021;28:167-176.
Electronic prescribing systems (such as computerized provider order entry) can aid in medication reconciliation and prevent medication errors. In this systematic review, the authors found variable evidence about the effectiveness of these systems for medication error and harm reduction. Included studies reported reductions in error rates, but implementation of electronic systems did not result in less patient harm.
Special or Theme Issue
Emerging Classic
Health Informatics J. 2020;26:181-189;576-591;683-718;1017-1042;2295-2299;3123-3162.
This special collection examines the use of novel health information technology (HIT) to promote patient safety and challenges in examining the impact of those technologies. Articles featured in this issue include a focus on qualitative approaches to evaluating the impact of HIT on patient safety, particularly through a sociotechnical lens.
Miller FA, Young SB, Dobrow M, et al. BMJ Qual Saf. 2020;30:331-335.
The COVID-19 pandemic has raised concerns about medical product shortages and demand surges, and the resulting effects on patient safety. This viewpoint discusses medical product supply chain vulnerabilities heightened by the COVID-19 pandemic. The authors summarize the evidence on supply chain resilience and medical product shortage, provide examples to illustrate key vulnerabilities, and discuss reactive and proactive solutions for medical product shortage.
Traylor AM. Am Psychol. 2021;76:1-13.
The COVID-19 pandemic has dramatically affected the psychological and emotional well-being of health care workers. This article summarizes the COVID-19-related psychological effects on healthcare workers and the detrimental impact on team effectiveness. The authors recommended actions to mitigate the effects of stress on team performance and patient outcomes and discuss how teams can recover and learn from the current crisis to prepare for future challenges.
Arriaga AF, Szyld D, Pian-Smith MCM. Anesthesiol Clin. 2020;38:801-820.
Debriefing is an established strategy teams use to learn from critical events, reduce event occurrence, and improve failure response. This review examines how debriefing principles can be embedded for use of the practice in real time, rather than developed in simulated circumstances, to improve anesthesia safety.
Corny J, Rajkumar A, Martin O, et al. J Am Med Inform Assoc. 2020;27:1695–1704.
Machine learning can improve the accuracy of clinical decision support (CDS) tools. This single-site study used data from the electronic health record (EHR) and clinical pharmacist review to test the accuracy of a hybrid CDS system to identify prescriptions with high risk of medication error. The machine-learning based approach was more accurate than existing techniques such as the traditional CDS system and can improve the reliability of prescription checks in an inpatient setting.  
Noursi S, Saluja B, Richey L. J Racial Ethn Health Disparities. 2021;8:661-669.
This study used ecological systems theory to review the literature on the root causes of racial disparities in maternal morbidity and mortality at the individual, interpersonal, community, and societal levels. Factors influencing disparities include access to preconception and prenatal care, implicit bias among health care providers, the need for quality improvement among black-serving hospitals, and policies such as parental leave. The authors also identify interventions likely to reduce disparities, such as improving health professional education, alternate prenatal care providers, and reforming Medicaid policies.
Sud A, Torr B, Jones ME, et al. Lancet Oncol. 2020;21:1035-1044.
This study modeled the impact of different scenarios of COVID-19 lockdown-accumulated backlog in cancer referrals on cancer survival. Results suggest that, for many cancer patients, treatment delays of 2-6 months will lead to a substantial proportion of patients with early-stage tumors progressing from having curable to incurable disease. Results also indicate that even small delays (e.g., 2 months) can lead to substantial survival decrements among younger patients; among adults 70 years of age and older, balancing risk of death between cancer and COVID-19 is important.  
Nafiu OO, Mpody C, Kim SS, et al. Pediatrics. 2020;146:e20194113.
The authors analyzed National Surgical Quality Improvement Program (NSQIP) Pediatric data from 2012 through 2017 to explore racial differences in postsurgical complications among healthy children. Compared to white children, African American children were three times as likely to die within 30 days after surgery and were more likely to develop postoperative complications and serious adverse events. These results can help guide future research exploring the mechanisms underlying racial differences in postsurgical outcomes in children.
Larouzee J, Le Coze J-C. Safety Sci. 2020;126:104660.
This article describes the development of the “Swiss cheese model,” (SCM) and the main criticisms of this model and the motivation for these criticisms.  The article concludes that the SCM remains a relevant model because of its systemic foundations and its sustained use in high-risk industries and encourages safety science researchers and practitioners to continue imagining alternatives combining empirical, practical and graphical approaches.
Wu AW, Buckle P, Haut ER, et al. J Patient Saf Risk Manag. 2020;25:93-96.
This editorial discusses priority areas for maintaining and promoting the well-being of the healthcare workforce during the COVID-19 pandemic. The authors discuss the importance of providing adequate personal protective equipment (PPE), supporting basic daily needs (e.g., provision of in-hospital food stores), ensuring frequent and visible communication, supporting mental and emotional well-being, addressing ethical concerns, promoting wellness, and showing gratitude for staff.