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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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Tennen H; Affleck G.
This detailed review summarizes existing evidence on how people adapt to threatening events by blaming others. Discussion includes a synthesis of past work and explanations for findings from both the psychoanalytic perspective and the social psychology literature. Based on their assessment that these explanations fall short, the authors present a different model that focuses on factors influencing the incidence of blaming others and the consequences of doing so. Their model argues for a relationship between situational factors and personal characteristics, with interpersonal and intrapersonal mediators playing a role, which ultimately leads to adaptation and blame of others. They include a discussion of limitations in their proposed model as well as recommendations for future study.
Baker R, Norton PG, Flintoft V, et al. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2004;170:1678-86.
Using methodology originally developed for the Harvard Medical Practice Study, the authors reviewed more than 4000 hospitalizations from 20 Canadian hospitals in order to estimate the degree of iatrogenic harm suffered by patients.  Overall, 7.5% of patients suffered at least one adverse event, of which more than one-third were felt to be preventable.  These data are similar to prior studies conducted in the United States and Australia, but (as with prior studies) reviewer agreement on the presence and preventability of errors was only moderate.
Lingard L, Espin S, Whyte S, et al. Quality & safety in health care. 2004;13:330-4.
This study used direct observation of 48 surgical procedures to characterize deficits in communication among team members.  Problematic communication occurred in nearly one-third of all exchanges between team members, and appeared to have direct effects on patient safety through increasing tension and creating the need for workarounds.  Communication and teamwork in the operating room was the subject of a classic study of safety culture.
Chang A, Schyve PM, Croteau RJ, et al. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2005;17:95-105.
The rapid increase in research and publications on patient safety following the landmark Institute of Medicine report resulted in the need for a common set of definitions and terminology for patient safety concepts.  To achieve this goal, the authors developed a taxonomy based on a systematic literature review.  The taxonomy, which has been widely accepted since its publication, consists of 5 primary classifications that can be used to classify an error:  impact, type, domain, cause, and prevention or mitigation.
Altman DE, Clancy CM, Blendon RJ. New England Journal of Medicine. 2004;351.
This commentary offers a perspective on the progress made since release of the IOM report in 1999. The authors discuss the growing number of stakeholders involved in safety and the need for both public and private sectors in shaping the next 5 years of progress. They discuss some of the success and the tremendous work that lies ahead in framing a common vision for the future of patient safety efforts. Two similar articles reflected on this 5-year period as well, one published in Health Affairs and the other in JAMA.
Wachter RM. Health affairs (Project Hope). 2004;Suppl Web Exclusives:W4-534-45.
This commentary discusses the progress made since the IOM report by reviewing the context to the patient safety movement, how health care became so unsafe, and what broad categories have played a role in shaping the current patient safety milieu. The author, who also wrote Internal Bleeding, provides a grade for the broad categories impacting safety efforts, which include regulation, error-reporting systems, information technology, the malpractice system, and workforce and training issues. Two similar articles reflected on this 5-year period, one published in the New England Journal of Medicine and the other in the Journal of the American Medical Association.
Walshe K, Shortell SM. Health affairs (Project Hope). 2004;23:103-11.
The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the Bristol Royal Infirmary cardiac surgery scandal—to determine the nature of the system factors that resulted in patient harm.  In most cases, problems were well known, but not addressed, indicating pervasive problems with safety culture and barriers to reporting and investigation of such incidents.  The authors call for improvements in reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures.  
Frankel A, Graydon-Baker E, Neppl C, et al. Jt Comm J Qual Saf. 2016;29.
This study shares the concept of an intervention that brings senior executives to the bedside and uses them to engage frontline staff and learn about ongoing safety issues. The authors share the experiences of their institution in implementing this activity in nearly 50 clinical areas, how they managed the collected data, and used it to drive improvement activities. They provide a series of sample questions used by executives to foster discussion and also an example of the reports generated from the effort. A later randomized control trial demonstrated the positive impact of this intervention on safety culture.
Howard S K, Gaba D M, Smith B E, et al. Anesthesiology. 2003;98(6):1345-1355.
This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.
Rogers AE, Hwang W-T, Scott LD, et al. Health Aff (Millwood). 2004;23(4):202-212.
This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.