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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

Huang SS, Septimus E, Kleinman K, et al. N Engl J Med. 2013;368.

Healthcare associated infection is a leading cause of preventable illness and death. Methicillin-resistant Staphylococcus aureus (MRSA) is a virulent, multi-drug resistant infection increasingly seen across healthcare settings. This... Read More

All Classics (730)

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Shah T, Patel-Teague S, Kroupa L, et al. BMJ Quality & Safety. 2018;28.
Alert fatigue associated with electronic health records (EHRs) contributes to primary care physician burnout and can increase medication errors. The phenomenon is especially well-described in the Veterans Affairs (VA) system, where providers receive more than 100 alerts per day, which require an average of 85 seconds to address. This study describes a nationwide VA initiative to reduce EHR alerts in primary care and teach providers to process alerts more efficiently. Alerts decreased by a small but significant amount—from an average of 128 per day to an average of 116 per day. Providers who received the most alerts before the initiative experienced the largest alert reduction. A PSNet perspective described a way forward in improving EHR safety.
Martin GP, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27(9):710-717.
A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.
Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319(10):1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Abbott TEF, Ahmad T, Phull MK, et al. British journal of anaesthesia. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Axeen S, Seabury SA, Menchine M. Ann Emerg Med. 2018;71(6):659-667.e3.
As deaths and overdoses related to opioid use have increased, physician prescribing behavior is under greater scrutiny. Prior research has shown significant variation in opioid prescribing among emergency medicine physicians, but the degree to which emergency department prescribing contributes to overall opioid prescribing remains unknown. This retrospective study used data from the Medical Expenditure Panel Survey from 1996 to 2012 and found that the quantity of opioids prescribed increased by 471% during the study period. While the percentage of opioids prescribed in the ambulatory setting increased from 71% in 1996 to 83% in 2012, the percentage of opioids prescribed in the emergency department decreased from 7.4% in 1996 to 4.4% in 2012. Based on these findings, the authors suggest that interventions designed to reduce opioid prescribing should target the outpatient setting rather than the emergency department. A past PSNet perspective discussed opioid medications and associated patient safety risks.
Liberman AL, Newman-Toker DE. BMJ Qual Saf. 2018;27(7):557-566.
Patient safety measurement remains challenging. This article describes a framework to address gaps in measuring diagnostic error. The authors propose utilizing big data to develop diagnostic performance dashboards and benchmarking tools that support proactive learning and improvement strategies.
Phillips JM, Stalter AM, Winegardner S, et al. Nurs Forum. 2018;2018(3):286-298.
Unprofessional behavior among clinicians adversely affects patient safety and the quality of care. This literature review sought to apply a systems approach to studies of workplace civility in nursing. The included studies demonstrated that rude behavior is perceived to diminish care quality, increase risk of adverse events, and worsen patient satisfaction. Researchers identified triggers for workplace incivility, such as negative organizational climate and power imbalances, as well as consequences including low self-esteem and decreased productivity. The authors note that high stress environments can foster incivility and lead to burnout. They recommend practice-based competency in civility in order to improve patient safety. A previous PSNet perspective discussed how to identify and manage problem behaviors.
Olson APJ, Graber ML, Singh H. Journal of general internal medicine. 2018;33:1187-1191.
Research is increasingly focusing on diagnostic errors and strategies to reduce them. The challenges of measuring diagnostic difficulties has hindered progress. This commentary outlines a conceptual approach to identifying "undesirable diagnostic events." The authors propose developing a list of clinical contexts and specific diseases prone to diagnostic error. Candidate conditions should be diagnosable in routine practice with a clear reference standard and defined diagnostic process. They also contend that measures should be constructed for relatively common conditions that are often misdiagnosed and for which delayed diagnosis could lead to harm, such as delayed cancer diagnosis. The authors propose designing and testing diagnosis measures based on this framework. A previous PSNet perspective by the senior author, Hardeep Singh, discussed momentum in the field of diagnostic error over the past several years.
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. JAMA internal medicine. 2018;178:375-382.
Preventable harm is common during and after hospital discharge. Pharmacist-delivered medication reconciliation has been proposed as a strategy to reduce adverse medication events and readmissions. Investigators conducted a three-arm randomized controlled trial comparing the effect of pharmacist-delivered medication reviews, motivational interviews, and postdischarge follow-up with nursing homes, primary care providers, and pharmacies (extended intervention); simple inpatient medication reconciliation (basic intervention); and usual care (no intervention) on outcomes for medically complex patients. The extended intervention reduced hospital readmissions and emergency department visits within 180 days of discharge while the basic intervention did not. This trial was large, robustly conducted, and demonstrated a durable improvement in safety for patients at increased readmission risk. A previous Annual Perspective explored tools for safer transitions of care.
Dzau VJ, Kirch DG, Nasca TJ. New England Journal of Medicine. 2018;378.
Physician burnout remains a critical threat to physician well-being and patient safety. Prodigious documentation requirements, escalating productivity demands, and deleterious organizational culture all contribute to physicians burning out at twice the rate of other professionals. In this commentary, leaders of the National Academy of Medicine, Association of American Medical Colleges, and Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout, teach about its dangers, and foster meaningful solutions. A related editorial highlights successful burnout initiatives such as standardized assessments and team-based models of primary care to reduce physicians' clerical burden. An Annual Perspective explored the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
Liberati EG, Peerally MF, Dixon-Woods M. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2018;30:39-43.
The field of patient safety has long looked to high reliability organizations like aviation or nuclear power for solutions, but it is unclear how well such approaches translate to health care settings. In this study, researchers asked clinicians to identify safety hazards from their own work and then propose solutions. After applying a systems thinking framework to clinicians' solution ideas, they found that most of the clinician-generated safety approaches would be considered ineffective by high reliability standards. The authors suggest that industrial frameworks are an imperfect match for health care settings and should be used with caution. A recent PSNet interview with the study's senior author, Mary Dixon-Woods, discusses the sociology of health care versus other industries.
Brat GA, Agniel D, Beam A, et al. BMJ. 2018;360:j5790.
Harm from opioids is a widely recognized patient safety concern. In this retrospective cohort study, investigators examined the effect of postoperative opioid prescribing in patients who had never received opioids before. As with prior studies, they found increased subsequent misuse of opioids among patients who received larger quantities of opioid medications following surgery compared to those who received fewer opioid medications. Longer duration of postoperative opioid prescription was also associated with higher odds of future diagnosis of opioid misuse. This study adds to evidence demonstrating the potential harms associated with even short-term opioid prescription. A recent PSNet interview discussed the opioid epidemic and strategies to address this growing patient safety concern.
Bhise V, Meyer AND, Menon S, et al. Int J Qual Health Care. 2018;30(1):2-8.
Reducing diagnostic error is an area of increasing focus within patient safety. However, little is known about how patients perceive physician communication regarding diagnostic uncertainty. In this study, participants (parents of pediatric patients) were assigned to read one of three clinical vignettes each describing a different approach to a physician communicating diagnostic uncertainty; they were then asked to answer a questionnaire. Researchers found that explicit expression of diagnostic uncertainty by a physician was associated with negative perceptions of physician competence as well as diminished trust and satisfaction with care, whereas more implicit language was not. A past Annual Perspective highlighted some of the challenges associated with diagnostic error.
Parent B, LaGrone LN, Albirair MT, et al. JAMA surgery. 2018;153:464-470.
Handoffs represent a significant risk to patient safety. Standardizing communication during the handoff process has the potential to reduce harm. In this trial, researchers assessed the impact of a standardized handoff curriculum on perceived interprovider communication in eight intensive care units (ICUs) across two hospital systems. Although the curriculum was perceived to improve shift preparedness among providers, they found no association with better patient outcomes in the ICUs, including length of stay, duration of mechanical ventilation, or reintubations. An accompanying editorial suggests that further research on standardized handoffs in the ICU is necessary to better understand the potential for improving patient outcomes. A previous PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319(2):143-153.
Handoffs between providers are inevitable and are known to introduce risks. This retrospective population-based cohort study in Canada examined the effects of intraoperative handoffs between anesthesiologists on major complications, readmissions, and 30-day mortality among patients undergoing surgery. After adjustment for patient and site characteristics, patients who experienced an anesthesiologist handoff had higher rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. The number of surgeries in which a handoff occurred increased over time during the 6-year study period. These results suggest that limiting intraoperative anesthesiologist handoffs may improve safety. However, a related editorial posits that reducing handoffs is a simplistic solution that may have unintended consequences and instead recommends that quality improvement approaches, such as developing standardized handoff procedures, may result in more meaningful enhancements for intraoperative anesthesia safety.
Campione J, Famolaro T. Joint Commission journal on quality and patient safety. 2018;44:23-32.
Measuring hospital safety culture is considered a best practice supported by both the Agency for Healthcare Research and Quality (AHRQ) and the Leapfrog Group. Although the data linking positive safety culture to patient outcomes is inconclusive, establishing a strong culture of safety is considered essential to patient safety. Researchers analyzed AHRQ Survey on Patient Safety Culture data submitted by 536 hospitals from 2007 through 2014 and identified 6 large (> 400 beds) hospitals demonstrating significant improvement over time. They then conducted interviews with quality leaders from those institutions. Qualitative analysis of interview transcripts revealed common best practices across those hospitals, including systematic safety culture measurement, widespread communication of results, both leadership and frontline engagement in improvement efforts, and implementation of patient safety initiatives. A PSNet perspective discussed how to improve safety culture.
Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Harbaugh CM, Lee JS, Hu HM, et al. Pediatrics. 2018;141(1):e20172439.
Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.
Ravi B, Pincus D, Wasserstein D, et al. JAMA internal medicine. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
Aldridge C, Bion J, Boyal A, et al. Lancet (London, England). 2016;388:178-86.
In-hospital mortality for many conditions is higher on the weekends than on weekdays—a phenomenon known as the weekend effect. Some hypothesize lower specialty physician staffing levels on weekends explains the mortality difference. This cross-sectional study compared specialist staffing levels and mortality rates at 115 hospitals in the English National Health Service on Sundays compared to Wednesdays. Researchers found a higher mortality rate and lower intensity of specialty services on weekends, but there was no correlation between the two ratios. Although this study is not definitive, it does imply that alternate mechanisms may explain the weekend effect, such as case mix differences, variation in nonphysician staffing, or lower availability of diagnostic services. A previous PSNet interview discussed the weekend effect in health care.