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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 (1064)

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Displaying 81 - 100 of 1064 Results
Displaying 81 - 100 of 1064 Results
van Dael J, Reader TW, Gillespie A, et al. BMJ Qual Saf. 2020;29:684-695.
This article reviewed 74 academic and 10 policy resources, as well as interviewed 13 experts, to understand how to effectively integrate patient-centric complaint handling with quality monitoring and improvement. Findings highlight the need for standardized methods to use and report complaints data, novel policy strategies, and analysis strategies to generate actionable learning insights and translation into quality improvement by affecting leadership and safety culture are discussed.
Salas E, Bisbey TM, Traylor AM, et al. Ann Rev Org Psychol Org Behav. 2020;7:283-313.
This review discusses the importance of teamwork in supporting safety, psychological states driving effective safety performance, organizational- and team-level characteristics impacting safety performance, and the role of teams in safety management.
Commentary
Emerging Classic
Thomas EJ. BMJ Qual Saf. 2019;29:4-6.
Achieving “zero harm” has been advocated as a patient safety goal. This editorial proposes that the conversation shift from striving to achieve absolute safety (Zero Harm) towards actively managing risk using both reactive and proactive approaches to safety management.
Mello MM, Frakes MD, Blumenkranz E, et al. JAMA. 2020;323:352-366.
This systematic review synthesized evidence from 37 studies to examine the association between malpractice liability risk and healthcare quality and safety. The review found no evidence of association between liability risk and avoidable hospitalizations or readmissions, and limited evidence supporting an association between risk and mortality (5/20 studies) or patient safety indicators or postoperative complications (2/6 studies).
Carayon P, Wooldridge AR, Hoonakker P, et al. App Ergon. 2020;84:103033.
This narrative review describes the Systems Engineering Initiative for Patient Safety (SEIPS) and SEIPS 2.0 models, which provide a framework for integrating human factors and ergonomics into healthcare quality and patient safety improvements. The authors propose a SEIPS 3.0 model which would include the patient journey, defined by the authors as “the spatio-temporal distribution of patients interactions with multiple care settings over time.”
Montoy JCC, Coralic Z, Herring AA, et al. JAMA Intern Med. 2020;180:487-493.
Prescription opioids play a significant role in the ongoing opioid crisis. This study examined whether reducing the default settings in the electronic health record (EHR) for number of opioid tablets for prescriptions could lower the number of pills actually prescribed by 104 health care professionals at two large, urban emergency departments. Results suggest that this easy to implement, low-cost intervention could be helpful in combatting the opioid epidemic.
Thibaut BI, Dewa LH, Ramtale SC, et al. BMJ Open. 2019;9:e030230.
This exploratory systematic review aimed to describe the state of the research on patient safety in inpatient mental health settings. Authors included 364 papers, representing 31 countries and data from over 150,000 participants. The existing research base was categorized into ten broad safety categories – interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorized leave, clinical decision making, falls, and infection prevention/control; papers were of varying quality with the majority of papers assessed as “fair”. The authors note that several areas of patient safety in inpatient mental health are particularly understudied, such as suicide, as the review only yielded one study meeting inclusion criteria.
Sanghavi P, Pan S, Caudry D. Health Serv Res. 2020;55:201-210.
Nursing Home Compare publicly available reports on the quality and safety of care provided by nursing homes in the United States. Prior research has found that Nursing Home Compare does not accurately capture patient safety performance. This study compared falls with injury data self-reported by nursing homes against those identified in Medicare claims data and found that falls with injury were substantially underreported by nursing homes, indicating that that the data used by Nursing Home Compare may be inaccurate.
McHugh SK, Lawton R, O'Hara JK, et al. BMJ Qual Saf. 2020;29:672-683.
Team reflexivity represents the way individuals and team members collectively reflect on actions and behaviors, and the context in which these actions occur.  This systematic review identified 15 studies describing the use of team reflexivity within healthcare teams. Included interventions, most commonly simulation training  and video-reflexive ethnography, focused on the use of reflexivity to improve teamwork and communication. However, methodological limitations of included studies precluded the authors from drawing conclusions around the impact of team reflexivity alone on teamwork and communication.
Boggan JC, Shoup JP, Whited JD, et al. J Gen Intern Med. 2020;35:2136-2145.
Remote triage, which can be delivered via telephone, email or video conference, has been linked to potential adverse events. This systematic review evaluated the effects of remote triage systems on healthcare utilization and patient safety outcomes. Of the eight studies identified, three cluster RCTs found high rates of call resolution in local, practice-based triage services compared with regional or national services. Two cluster trials examined the effects of remote triage on mortality, hospitalizations and ED visits; neither reported statistically significant differences indicating increased risk for these patient safety outcomes.
McKinney SM, Sieniek M, Godbole V, et al. Nature. 2020;577:89-94.
Research has found that artificial intelligence (AI) can improve diagnostic accuracy, but less is known about its performance in clinical settings. To evaluate the performance of AI in identifying breast cancer in a clinical setting, this study deployed AI in a curated, representative data set from the UK (25,856 women) and an enriched dataset from the US (3,097 women), as well as compared the performance of AI to that of six human radiologist readers. They used biopsy-confirmed cancer patients to evaluate AI predictions. The authors reported a reduction in both false positives and false negatives using AI and found that the AI system was more accurate than the radiologists.
Agarwal S, Bryan JD, Hu HM, et al. JAMA Netw Open. 2019;2:e1918361.
In 2016, the Centers for Disease Control and Prevention (CDC) issued opioid prescribing guidelines that recommended limiting the duration of therapy for acute pain. Research has found that the guidelines have changed opioid prescribing in the emergency department, but less is known about the impact on postoperative opioid prescribing. This study examined the effect of opioid prescribing duration limits in Massachusetts and Connecticut on postoperative prescribing. Dosing duration limits resulted in decreases in postoperative prescription size and days supplied in Massachusetts but not in Connecticut.
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Ree E, Wiig S. Nurs Open. 2020;7:256-264.
Using survey data from home healthcare works in Norway, this study examined the relationship between patient safety culture and transformational leadership, job demands/resources and work engagement. The authors found that transformational leadership, job resources and work engagement were positively correlated with patient safety culture, and that transformational leadership was the strongest predictor for safety culture, which is consistent with prior research.
Rehder KJ, Adair KC, Hadley A, et al. Jt Comm J Qual Saf. 2020;46:18-26.
This study used a brief survey to evaluate disruptive behaviors in one large health system, and its relationship to safety culture. Disruptive behaviors (most commonly bullying and inappropriate discontinuation of communication, such as hanging up the phone) were noted by more than half of individuals surveyed and occurred in nearly all work settings. Greater exposure to disruptive behaviors was associated with poorer teamwork climate, safety climate, and job satisfaction
Kemper KJ, Schwartz A, Wilson PM, et al. Pediatrics. 2020;145:e20191030.
Physician burnout has been associated with increased patient safety incidents. A recent national survey of pediatric residents found burnout rates exceeded 50%. The survey found that risk of burnout was associated with reported stress, sleepiness, dissatisfaction with work-life balance and recent medical error. Burnout rates were lowest among residents reporting empathy, self-compassion, quality of life, and confidence in providing compassionate care.
O’Mahony D. Expert Rev Clin Pharmacol. 2019;13:15-22.
STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are criteria used as a tool for clinicians to review potentially inappropriate medications in older adults and have been endorsed as a best practice by some organizations.  This article, written by the developer of STOPP/START, describes its history and updates, and current large-scale trials involving the use of specialty software that automates the process as a potential patient safety improvement.
Commentary
Emerging Classic
Yorio PL, Edwards J, Hoeneveld D. Safety Sci. 2019;120:402-410.
This paper discusses the relationship between national culture and safety culture, and how national culture influences an individual’s organizational beliefs, assumptions and values related to safety and then how those influence worker perception. The authors provide practical suggestions and directions for future research on organizational patient safety culture.
Wears R, Sutcliffe K. New York, NY: Oxford University Press; 2019. ISBN: 9780190271268.
The modern patient safety movement has struggled to achieve the goals set forth in To Err Is Human. This book surveys the evolution of the collective error reduction effort in health care. The authors analyze the experience through social, legal, market, psychological and medical practice trends. They submit that the clinician-driven focus of improvement is reducing the momentum needed for lasting change. The publication provides recommendations to generate the improvement needed do minimize patient harm, notably the involvement of safety scientists.
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Jt Comm J Qual Patient Saf. 2019;46:3-10.
Clinical decision support (CDS) tools help identify and reduce medication errors but are limited by the rules and types of errors programmed into their alerting logic and their high alerting rates and false positives, which can contribute to alert fatigue. This retrospective study evaluates the clinical validity and value of using a machine learning system (MedAware) for CDS as compared to an existing CDS system. Chart-reviewed MedAware alerts were accurate (92%) and clinically valid (79.7%). Overall, 68.2% of MedAware alerts would not have been generated by the CDS tool and estimated cost savings associated with the adverse events potentially prevented via MedAware alerts were substantial ($60/drug alert).