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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.

Popular Classics

Wachter RM, Gupta K. New York, NY: McGraw-Hill Professional; 2017. ISBN: 9781259860249.
The third edition of this widely read textbook, written by national leaders in patient safety, provides an in-depth introduction to the field. The new edition uses case studies to discuss the history of the patient safety movement, the epidemiology of safety hazards, specific error types, and strategies to improve safety in clinical microenvironments and at the organizational level. Substantial new content has been added to highlight emerging areas of the field, such as safety culture, policy and regulatory initiatives to improve safety, and diagnostic errors.
Makary MA, Sexton B, Freischlag JA, et al. Journal of the American College of Surgeons. 2006;202:746-52.
This Agency for Healthcare Research and Quality (AHRQ)–supported study advocates for the use of the Safety Attitudes Questionnaire (SAQ) as a validated method to evaluate teamwork, communication, and the quality of collaborative care. Investigators surveyed more than 2000 surgeons, anesthesiologists, and operating room nurses in 60 hospitals to demonstrate the substantial differences in self-reported teamwork ratings. For instance, physicians rated teamwork as good, whereas nurses rated it as mediocre. These findings mirror a past study comparing teamwork perceptions in the operating room with those in a cockpit. As teamwork remains a critical component of patient safety, the authors propose that a better understanding of these existing disconnects can drive future improvement efforts. The same authors recently described using the SAQ as a tool to evaluate safety culture in surgical settings.
Johnson B, Abraham M, Conway J, et al. Bethesda, MD: Institute for Family-Centered Care; April 2008.
This report summarizes results from a conference of consumers, health care professionals, and administrative leaders about improving the health care system and advancing patient-centered care. Key recommendations include involving patients and families in health care leadership, through measures such as patient advisory councils and partnering with community organizations. The report also emphasizes the role of health literacy in providing patient-centered care.
Runciman WB, Sellen A, Webb RK, et al. Anaesthesia and intensive care. 1993;21:506-19.
This review discusses the psychology of human error in the context of anesthesia. The authors provide definitions of, and describe the relationships between, errors, incidents, and accidents while drawing examples from the Australian Incident Monitoring Study. They explore a classification system for errors, including discussion of relevant taxonomic forms of “active” errors and contributing factors to “latent” errors. The discussion continues with strategic suggestions to both reduce and manage errors, which entail adequate collection, organization, and analysis of reported and recorded events. The authors also advocate for systematic understanding of errors as catalysts for future prevention efforts.

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Horsham, PA; Institute for Safe Medication Practices: February 2019.
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.
Kang H, Wang J, Yao B, Zhou S, Gong Y. JAMIA Open. 2019;2:179–186.
Improved health information technology (IT) event databases are necessary to better understand safety events associated with health IT, but such databases are lacking. This study describes the use of the Food and Drug Administration Manufacturer and User Facility Device Experience database as a source to identify adverse events related to health IT. Frequently identified contributing factors to such events included hardware and software problems as well as user interface design issues.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154(1):e184234.
This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.
Panagioti M, Geraghty K, Johnson J, et al. JAMA internal medicine. 2018;178:1317-1330.
Physician burnout has long been considered a patient safety hazard. This meta-analysis of 47 studies of burnout and patient safety found that burnout is associated with increased risk of patient safety incidents, lapses in professionalism, and lower patient satisfaction. The magnitude of these effects varied among the studies included in the analysis, and the quality of the studies ranged from low to moderate rigor. Studies in which physicians self-reported patient safety concerns were more likely to show a link between burnout and safety. The authors raise the concern that conventional hazard detection methods may not capture incidents due to burnout. A related editorial by Dr. Mark Linzer calls for rigorous quality improvement studies to address the high prevalence of burnout among physicians.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27(12):954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Doctor JN, Nguyen A, Lev R, et al. Science (New York, N.Y.). 2018;361:588-590.
High-risk opioid prescribing by providers contributes to opioid misuse. Prior studies have shown that patients frequently receive opioid prescriptions even if they have a history of overdose. In this randomized trial involving 861 providers prescribing opioids to 170 patients who experienced fatal overdose, providers in the intervention arm were notified about patients' deaths by the county medical examiner while those in the control arm were not. Researchers found that milligram morphine equivalents prescribed to the patients of providers who received the death notifications decreased by almost 10% in the 3-month period following the intervention. There were no significant changes in the prescribing patterns of the control group. An Annual Perspective discussed patient safety and opioid medications.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ quality & safety. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. BMJ quality & safety. 2019;28:39-48.
This study developed a measure of patient safety leadership style for nurse managers. Researchers found that their measure of control-based versus commitment-based safety management was valid and reliable after testing among clinical nurses.
Larochelle MR, Bernson D, Land T, et al. Ann Intern Med. 2018;169(3):137-145.
Nationally, opioid overdose remains a common cause of preventable death. Treatment of opioid use disorder with opioid replacement therapy, specifically methadone or buprenorphine, is a potent but underutilized strategy for reducing opioid-related harm. Investigators employed a prospective cohort study to follow 17,568 adults who were treated in Massachusetts emergency departments for a nonfatal opioid overdose. About 15% received opioid replacement therapy in the subsequent 2 years. Patients on opioid replacement therapy were substantially less likely to die from opioids or any other cause. An accompanying editorial from leaders at the National Institute on Drug Abuse highlights strategies to increase the number of Americans offered these life-saving therapies. The editorial also notes the alarming number of patients who received prescriptions for short-acting opioids and benzodiazepines after an opioid overdose. A past Annual Perspective and PSNet perspective delineated other strategies for addressing the opioid crisis.
Haffajee RL, Mello MM, Zhang F, et al. Health Aff (Millwood). 2018;37(6):964-974.
The opioid epidemic is a well-recognized national patient safety issue. High-risk opioid prescribing can contribute to misuse. Provider prescribing has come under increased scrutiny and several states have implemented prescription drug monitoring programs (PDMPs). Prior research suggests that such programs have the potential to reduce opioid-related harm. This study used commercial claims data to assess the impact of PDMPs implemented in four states in 2012–2013 on opioid prescribing. By the end of 2014, all four states with PDMPs demonstrated a greater reduction in the average amount of morphine-equivalents prescribed per person per quarter compared with states without these programs. One state demonstrated a decrease in the percentage of people who filled an opioid prescription. The authors conclude that PDMPs have the potential to reduce opioid use and improve prescribing practices. An Annual Perspective highlighted safety issues associated with opioid medications.
Finn KM, Metlay JP, Chang Y, et al. JAMA Intern Med. 2018;178(7):952-959.
Over the past decade, with the goal of improving both the educational experience and patient safety, the Accreditation Council for Graduate Medical Education has introduced regulations restricting resident duty hours and requiring graded supervision by faculty physicians. While many studies have evaluated how duty hour restrictions influence safety outcomes, the impact of different supervisory strategies has been less studied. Conducted on an internal medicine teaching service, this randomized controlled trial examined the effect of two supervisory strategies on patient safety and the educational experience for housestaff. Increased direct supervision (faculty physician physically present for duration of morning rounds, including patient care discussions and encounters with newly admitted and existing patients) was compared to standard supervision (faculty directly supervised residents only for new admissions, meeting later in the day to discuss existing patients). The study used a rigorous, previously developed methodology to track adverse event rates and found no significant difference in safety outcomes between the two groups. Residents perceived that greater supervision led to decreased autonomy in decision-making. Although the study evaluated only direct, in-person supervision, its findings demonstrate that—like reducing duty hours—increasing direct supervision of trainees does not necessarily translate to improving patient safety. The relationship between clinical supervision, education, and patient safety is discussed in a PSNet perspective.
Armstrong N, Brewster L, Tarrant C, et al. Social science & medicine (1982). 2018;198:157-164.
Measuring patient safety is critical to improvement. This ethnographic study examined the implementation of a patient safety measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure ulcers, harm from falls, catheter-associated urinary tract infection, and venous thromboembolism, with the goal of informing local improvement efforts. Investigators sought to examine how the measurement program was perceived by frontline staff. Despite the explicit emphasis on using the data for improvement, it was viewed as an external reporting requirement. The program was also viewed as a basis to compare organizations, especially because it included pay-for-performance incentives. The authors suggest that the intention of the program did not match the real-world considerations of participating health care systems and had the unintended consequence of creating potential for blame.
Freund Y, Goulet H, Leblanc J, et al. JAMA internal medicine. 2018;178:812-819.
In emergency departments (EDs), high medical acuity, incomplete information, and productivity pressures can contribute to preventable adverse events and near misses. Systems solutions have improved medication safety and team communication in EDs, but few interventions have meaningfully affected diagnostic and treatment errors. Investigators conducted a randomized controlled trial to evaluate the impact of ED physicians' cross-checking their diagnostic and treatment plans with another physician. Compared with standard care, patients whose physicians performed cross-checking were 40% less likely to experience a preventable adverse event or near miss. This study's design, large sample size, and ascertainment of patient-centered outcomes were particularly robust. A past WebM&M commentary and PSNet perspective examined other initiatives to improve emergency department safety.
Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. Worldviews on evidence-based nursing. 2018;15:16-25.
Although the practice of evidence-based medicine is an important strategy for improving the safety and quality of health care, consistent use of known best practices does not occur. In this study, researchers sought to assess nurse competency throughout the United States across 13 evidence-based practice competencies for nurses as well as 11 additional competencies for advanced practice nurses. They administered an anonymous online survey and received responses from 2344 nurses across 19 hospitals or health systems. In general, nurses reported a lack of competency across all 24 domains, but younger nurses and those with more training reported better competency. A recent PSNet interview discussed the role of nurses with regard to patient safety and outcomes.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25(4):385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
Haas S, Gawande A, Reynolds ME. JAMA. 2018;319:1765-1766.
Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.
Thomas LR, Ripp JA, West CP. JAMA. 2018;319:1541-1542.
Clinician burnout is a growing concern with known patient safety implications. This commentary describes a charter for health care organizations to prioritize physician well-being in order to preserve quality and safety of patient care. The charter includes elements known to contribute to safety, such as a positive work culture and leadership engagement. The authors call for reducing time spent on documentation and administration, consistent with prior studies. A related editorial emphasizes the importance of the physician–patient relationship in creating meaning and joy in physician work. A previous PSNet interview and perspective discussed the relationship between physician professional satisfaction and patient safety.
Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33(7):1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
Howe JL, Adams KT, Hettinger Z, et al. JAMA. 2018;319(12):1276-1278.
As electronic health records (EHRs) have become ubiquitous, our understanding of their benefits and potential harms has evolved. In particular, issues with EHR usability (the ease of understanding, learning, and using the interface) impair physician workflow and may result in harm to patients. In this study, investigators analyzed voluntary error reports from the Pennsylvania Patient Safety Authority and a multihospital academic health system for evidence of safety issues related to EHR usability. Although limited by the nature of the voluntary reports, which contained sparse details precluding assessment of causal factors, investigators did identify and categorize cases in which problems with EHR usability may have directly resulted in patient harm. Many EHR contracts with health care organizations include "hold harmless" clauses limiting the EHR vendors' legal liability, meaning that patients may not be able to seek compensation if EHR issues directly lead to harm. A WebM&M commentary discussed a case of contrast nephropathy arising in part due to a confusing EHR user interface.
Thorpe KE, Joski P, Johnston KJ. Health Aff (Millwood). 2018;37(4):662-669.
Infections with antibiotic-resistant organisms are increasingly common in hospitals and ambulatory care, primarily driven by overuse of antibiotics for treatment of nonbacterial illnesses. This economic analysis found that antibiotic-resistant infections have doubled in incidence since 2002, and they add approximately $1,400 to the cost of care for each patient with an antibiotic-resistant infection. The study was performed using data from the Medical Expenditure Panel Survey, which is conducted by AHRQ. This survey does not include data on institutionalized adults, such as residents of long-term care facilities. Since antibiotic-resistant infections are common in these patients, this study may actually underestimate the total economic burden of these infections. The devastating effects of an antibiotic-resistant infection for a health care practitioner were vividly illustrated in a PSNet perspective.