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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

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Lin LA, Bohnert ASB, Kerns RD, et al. Pain. 2017;158(5):833-839.
Opioids are known to be high-risk medications, and unsafe prescribing practices are common. This intervention at Veterans Affairs medical centers used an electronic dashboard to provide feedback to clinicians about high-risk opioid prescribing. Local champions implemented the dashboard tool and spearheaded safer opioid prescribing. Using an interrupted time series analysis, researchers determined that the intervention reduced two unsafe prescribing practices: high-dose opioid prescriptions and concurrent use of opioids and benzodiazepines. The authors suggest that this type of large-scale intervention could be applied in other health care systems to enhance opioid safety. A recent Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to foster safer opioid use.
Westbrook JI, Li L, Hooper TD, et al. BMJ Qual Saf. 2017;26(9):734-742.
This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.
Khan A, Coffey M, Litterer KP, et al. JAMA pediatrics. 2017;171:372-381.
Detecting adverse events remains a challenge across health care settings. This prospective study conducted in multiple pediatric inpatient settings used medical record review, clinician reports, and hospital incident reports to identify adverse events. Investigators compared adverse events detected with these mechanisms to adverse events identified through interviews with parents and caregivers of pediatric patients. As with previous studies, two physicians reviewed all incidents and rated the severity and preventability of all incidents. About half the incidents reported by family members were determined to be safety concerns; fewer than 10% of these incidents were felt to be preventable adverse events. Family-reported error rates were similar to error rates drawn from actively eliciting error reports from clinicians. Families were able to identify preventable adverse events that were not detected by any other method. Error rates calculated from hospital incident reports were much lower than those drawn from either clinician or family reports, consistent with prior studies. These results demonstrate that families can identify otherwise undetected adverse events and their input should be elicited in safety surveillance systems.
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.
Cooper WO, Guillamondegui O, Hines J, et al. JAMA surgery. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Obermeyer Z, Cohn B, Wilson M, et al. BMJ (Clinical research ed.). 2017;356:j239.
The emergency department is considered a high-risk setting for diagnostic errors. This analysis of Medicare claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged from an emergency department, even when no life-limiting illness was noted. Hospitals that admit a lower proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged patients, even after adjusting for patient characteristics. Consistent with prior studies relating patient outcomes to volume, higher-volume emergency departments had lower 7-day mortality among discharged patients. These results suggest that emergency department discharges may represent missed diagnoses. A WebM&M commentary discussed an incident involving a patient who died after being discharged from the emergency department.
Lawton R, O'Hara JK, Sheard L, et al. BMJ quality & safety. 2017;26:622-631.
Although patient engagement is widely recommended as a patient safety strategy, its impact on patient outcomes is unclear. In this cluster randomized trial, hospital wards were designated either to receive usual hospital care or to engage patients in safety by providing a questionnaire and an opportunity to report their positive and negative safety experiences. Investigators compared a global measure of safety, which included pressure ulcers, venous thromboembolism, catheter-associated urinary tract infections, and falls, between wards that engaged patients through this intervention with those that did not. While the participating hospital wards were able to collect safety feedback from patients in a feasible and acceptable manner, researchers found no statistically significant differences in safety outcomes in the patient engagement wards and the usual care wards. The authors conclude that evidence is insufficient to recommend this questionnaire-based patient engagement strategy as a way to enhance safety.
Carayon P, ed. Boca Raton, FL: CRC Press; 2017. ISBN: 9781439830338
Human factors principles are widely applied in high-risk industries to promote safety and are increasingly adapted by health care organizations to improve patient safety. This book provides an in-depth analysis of the intersection of design and process with the human element of health care to underscore their effects on patient safety and introduce strategies for improvement. The authors cover a wide range of health care topics including medical technology and telemedicine. A past PSNet perspective discussed the application of human factors engineering concepts.
Kellogg KM, Hettinger Z, Shah M, et al. BMJ Qual Saf. 2017;26(5):381-387.
Root cause analysis (RCA) is a process frequently employed by health care institutions to understand the sequence of events leading to an adverse event or near miss. Experts have previously highlighted flaws with the RCA process and suggested ways to improve it. In this study, researchers reviewed 302 RCAs and concluded that many of the proposed solutions were weak, consisting largely of educational interventions, changes to processes, and enforcing policy. A recent Annual Perspective explores ongoing problems with the RCA process and sheds light on opportunities to improve its application in health care.
Jørgensen KJ, Gøtzsche PC, Kalager M, et al. Ann Intern Med. 2017;166(5):313-323.
The overuse of medical care is increasingly recognized as a patient safety issue. Overdiagnosis can result in unnecessary use of medical care, subjecting patients to greater risk of harm. For example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading to further testing and unnecessary procedures. This study examined the impact of mammography screening on a cohort of women in Denmark. Researchers found that screening was not associated with decreased incidence of advanced cancer but increased incidence of nonadvanced tumors and ductal carcinoma in situ; the rate of overdiagnosis was significant. An accompanying editorial discusses overdiagnosis in breast cancer.
Wasfy JH, Zigler CM, Choirat C, et al. Annals of internal medicine. 2017;166:324-331.
Reducing hospital readmissions is an important patient safety objective. This pre–post study examined rates of hospital readmissions before and after the Centers for Medicare and Medicaid Services (CMS) enacted its nonpayment policy. Investigators separated hospitals into tiers of performance, considering hospitals with lowest readmission rates to be the highest performers. They found that across all levels of hospital performance, readmission rates for acute myocardial infarction, congestive heart failure, and pneumonia decreased after the Medicare Hospital Readmissions Reduction Program was introduced. Hospitals with the lowest performance prior to the nonpayment policy improved the most. These data are consistent with previous studies demonstrating the profound safety improvement following CMS nonpayment policies. A previous WebM&M interview discussed the potential benefits and limitations of insurers not paying for preventable complications.
Hyder JA, Hanson KT, Storlie CB, et al. Annals of surgery. 2017;265:639-644.
Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.
Anselmi L, Meacock R, Kristensen SR, et al. BMJ quality & safety. 2017;26:613-621.
Previous research has shown that patients admitted to the hospital on the weekend are at increased risk for worse outcomes, including mortality. This retrospective study examined more than 3 million emergency admissions to 140 hospital trusts in England between April 2013 and February 2014. Patient arrival times were recorded by day of the week and nighttime versus daytime. Using administrative data and standard risk adjustment, mortality rates were higher for patients arriving during the week on Wednesday and Thursday nights. Risk-adjusted mortality rates were also found to increase for patients arriving over the weekend from daytime on Saturday through nighttime on Sunday. However, when researchers adjusted for arrival by ambulance, higher mortality was statistically significant only for those patients arriving at the hospital during the day on Sunday. Investigators suggest that prior research supporting the weekend effect is overly reliant on administrative data, which may not accurately characterize illness severity. It is often debated whether the weekend effect could be due to factors related to the system of care (i.e., reduced staffing on weekends) or patient factors (i.e., increased severity of illness of patients admitted on the weekend). An Australian study sought to answer this question and found that certain diagnoses appeared to be associated with higher mortality for weekend admissions, largely due to health system factors.
Ferrah N, Lovell JJ, Ibrahim JE. J Am Geriatr Soc. 2017;65(2):433-442.
Older adults living in long-term care facilities face significant safety hazards. This systematic review examined medication errors in nursing homes and found a high prevalence of errors overall. The review revealed that a significant number of errors were related to handoffs and that 75% of these older patients received at least one potentially inappropriate medication. However, serious harm associated with medication use was reported for less than 1% of errors. The authors emphasize the difficulty of attributing harm to medications versus underlying illness in nursing home residents, and they call for designing safer systems for medication administration in nursing homes. A previous WebM&M commentary discussed challenges to ensuring patient safety in long-term care facilities.
Burlison JD, Quillivan RR, Kath LM, et al. J Patient Saf. 2020;16(3):187-193.
Hospitals often rely on voluntary patient safety event reporting systems to identify safety issues. However, significant barriers to reporting exist and most systems capture only a fraction of adverse events. In this study, researchers analyzed data from the AHRQ Hospital Survey of Patient Safety Culture to better understand what aspects of safety culture might affect event reporting. They found that multiple dimensions of safety culture, including feedback about error, were positively correlated with an increased frequency of events reported. To augment voluntary reporting, the authors recommend that institutions focus on providing feedback to reporters and communicate the resultant improvement efforts. A previous PSNet perspective highlighted the importance of providing feedback with regard to incident reporting.
Shehab N, Lovegrove MC, Geller AI, et al. JAMA. 2016;316(20):2115-2125.
Adverse drug events (ADEs) in outpatient settings can cause significant morbidity and mortality. Updating a prior study, this surveillance study identified more than 40,000 ADEs among 58 emergency departments in the United States. Investigators estimated that 4 emergency department visits for ADEs occurred per 1000 patients annually during the study period, with more than one-quarter of these visits resulting in hospitalization. Antibiotic reactions were the most common ADE for children. Among patients age 65 or older, anticoagulants, diabetes medications, and opioids were most commonly implicated in ADEs, as seen in a previous study. Medications considered inappropriate for older adults according to Beers criteria were involved in less than 2% of ADEs. The authors conclude that preventing ADEs requires attention to older adults and to antibiotic, anticoagulant, diabetes, and opioid medications, consistent with recommendations from the 2014 National Action Plan for Adverse Drug Event Prevention.
Brenner SK, Kaushal R, Grinspan Z, et al. J Am Med Inform Assoc. 2016;23:1016-36.
Health information technology (IT) has had a profound impact on health care. Although health IT has led to efficiency gains and improved safety, unintended consequences remain a concern. In this systematic review, researchers analyzed 69 studies from 2001 through 2012 that examined the use of health IT in a clinical setting and its effect on safety outcomes for patients. About one-third of the studies demonstrated a positive impact of health IT on patient safety outcomes, but many of these focused on the hospital setting, involved a single institution, and looked at decision support or computerized provider order entry. The authors suggest that future studies should focus on other areas in which the impact of health IT remains understudied, such as in outpatient and long-term care settings, and they underscore the need for higher quality research. A recent WebM&M commentary described the unintended consequences of health IT.
Rudd RA, Seth P, David F, et al. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452.
Opioid medications are frequently associated with adverse drug events in inpatient and outpatient settings. This surveillance report from the Centers for Disease Control and Prevention demonstrated that the magnitude of patient harm from opioid use is growing rapidly. Opioid overdose deaths are increasing each year, through 2015, and current rates are the highest ever recorded. The types of opioids most commonly involved in overdose deaths are natural and semisynthetic opioids, which are often prescribed as pain relievers. The authors suggest that the adoption of new prescribing guidelines and more widespread use of the opioid reversal agent naloxone will help address this growing epidemic. An earlier version of this article included data through 2014. A previous WebM&M commentary described a fatal opioid overdose.

Shekelle PG, Sarkar U, Shojania K, et al. Technical Brief No. 27. Rockville, MD: Agency for Healthcare Research and Quality; October 2016. AHRQ Publication No. 16-EHC033-EF.

Most patient safety research and initiatives have focused on the hospital environment, despite the fact that much of health care is delivered in outpatient settings. This technical brief explores gaps in the evidence base that hinder understanding of safety concerns and factors unique to ambulatory care. The evidence review supports use of pharmacist interventions to augment medication safety in outpatient settings. The authors also found that electronic health records have mixed effects on ambulatory safety. Key informants interviewed for the brief noted that studies on patient engagement and diagnostic error are lacking.
Vadnais MA, Hacker MR, Shah NT, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;43.
Cesarean delivery is associated with increased morbidity, mortality, longer hospital stays, and increased costs. From 2008 through 2015, a single tertiary care academic medical center implemented a quality improvement initiative designed to address factors influencing the rate of nulliparous term singleton vertex (NTSV) cesarean delivery rate. The initiative consisted of provider education, provider feedback, and implementation of new policies. The rate of NTSV cesarean delivery decreased from 34.8% to 21.2% and total cesarean delivery rate decreased from 40.0% to 29.1%. Researchers also noted a decline in the incidence of episiotomy and third-degree lacerations.