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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

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Chaparro JD, Classen DC, Danforth M, et al. J Am Med Inform Assoc. 2017;24:268-274.
Although computerized provider order entry (CPOE) for medications has reduced medication errors, it has also had unintended consequences. This simulation study used the validated Leapfrog evaluation tool to assess the safety of CPOE for medications for pediatric patients across multiple electronic health record (EHR) platforms. The investigators had clinicians familiar with the EHR enter prespecified unsafe orders into simulated patient records and note whether alerts or messages ensued. As demonstrated in prior work, many potentially unsafe medication orders did not lead to alerts. The authors report that repeated use of the tool led to improvement over time, which suggests the need for regular safety testing for EHRs after implementation.
Sinsky CA, Colligan L, Li L, et al. Annals of Internal Medicine. 2016;165.
Time spent with the electronic health record and performing administrative tasks has been linked to physician burnout, an important patient safety problem. This study used direct observation and time diaries to characterize the work of outpatient physicians. Investigators found that physicians spent about one-quarter of their time face-to-face with patients. Nearly half their work day was spent using the electronic health record and doing desk work. Participating clinicians spent 1–2 additional hours on the electronic health record at night. A PSNet interview with lead author Christine Sinsky calls for improving physician work satisfaction in order to improve patient safety.
Levinson DR; Department of Health and Human Services, Office of Inspector General; HHS; OIG.
The Office of the Inspector General (OIG) has issued a series of reports analyzing the incidence and preventability of adverse events among Medicare beneficiaries receiving care in acute care hospitals and skilled nursing facilities. This report used similar methodology based on trigger tools to determine adverse event incidence among patients in rehabilitation hospitals—post-acute care facilities that provide intensive rehabilitation to patients recovering from hospitalization for an acute illness or injury. The study found that 29% of patients experienced an adverse event during their stay, a proportion nearly identical to rates at acute care hospitals and skilled nursing facilities. Nearly half of the events were considered preventable, with the most common types of events including pressure ulcers, delirium, and medication errors. Nearly one-fourth of patients who had an adverse event required transfer to an acute care hospital for diagnosis or management, leading to a large increase in costs of care. Based on these data, the OIG has recommended that the Agency for Healthcare Research and Quality and Centers for Medicare and Medicaid Services disseminate information about patient harms in the rehabilitation setting and work to improve safety at rehabilitation hospitals. A previous WebM&M commentary discussed an adverse event at a rehabilitation facility.
Meara E, Horwitz JR, Powell W, et al. The New England journal of medicine. 2016;375:44-53.
Growing rates of opioid misuse endanger public health. The impact of legal restrictions to limit high-risk prescribing and resultant adverse events is unclear. One recent study found that opioid-related adverse events were effectively reduced in states with stringent prescription drug monitoring programs compared to states without such regulations. However, this study examined data regarding Medicare beneficiaries with disabilities before and after adoption of controlled-substance laws and found no significant decrease in rates of nonfatal overdose, high opioid doses, or receipt of opioids from four or more prescribers. These results suggest that current regulatory policy may not be sufficient to address high-risk prescribing practices among Medicare beneficiaries with disabilities. More work is needed to develop effective strategies to treat chronic pain safely in this high-risk population. A WebM&M commentary described risks related to prescribing opioids for patients with chronic pain.
Patrick SW, Fry CE, Jones TF, et al. Health Aff (Millwood). 2016;35(7):1324-1332.
Opioid medications carry high risk for adverse drug events, and increases in opioid abuse have led to an epidemic of overdose deaths. State-level prescription drug monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids. This study used secondary data sources to determine whether implementing a drug monitoring program decreased opioid overdose deaths compared to the pre-implementation period. States with more complete and timely opioid monitoring achieved greater overdose reductions compared to states with less comprehensive programs. These results clearly support universal implementation and strengthening of state prescription drug monitoring programs. A WebM&M commentary discussed a death due to an opioid overdose.
Barker AL, Morello RT, Wolfe R, et al. BMJ (Clinical research ed.). 2016;352:h6781.
Falls in hospitalized patients are a common source of preventable harm, and the incident is considered a never event when it results in serious injury. Conducted at six Australian hospitals, this cluster randomized controlled trial sought to evaluate the effectiveness of a bundled intervention on the incidence of falls on adult wards. The bundle included assessing patients' risk for falling along with several widely used tactics to prevent falls. Despite successful implementation of the fall prevention bundle, falls occurred just as frequently on intervention wards as control wards. This study is an important example of the need to rigorously evaluate safety interventions, even those that have high face validity. The authors conclude that since these interventions appear ineffective. Organizations should consider disinvestment in these practices because completing ineffective interventions consumes a significant amount of staff time and effort. A WebM&M commentary discussed a case involving a fall resulting in injury.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374(22):2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.
Li L, Rothwell PM, Study OV. BMJ (Clinical research ed.). 2016;353:i2648.
The weekend effect refers to the fact that mortality for several common conditions is higher in patients admitted on weekends compared to weekdays. While the mechanism for this effect is unclear, it likely varies for different disease processes. For example, prior studies have postulated that a weekend effect exists for patients with acute stroke. However, this study analyzed a large British database and found that many patients with a history of stroke who were later hospitalized for other reasons had their admission diagnosis inaccurately documented as acute stroke. This inaccuracy occurred more frequently in patients admitted on weekdays. Because the weekday admissions included many patients who were hospitalized for less morbid conditions, mortality appeared lower for patients admitted on weekdays than on weekends. When data was reanalyzed to include only those patients with a true acute stroke, no weekend effect was found. This study demonstrates the limitations of administrative data in analyzing patient safety issues.
de Jager E, McKenna C, Bartlett L, et al. World journal of surgery. 2016;40:1842-58.
The World Health Organization surgical safety checklist garnered a great deal of attention after initial studies showed remarkable reductions in postoperative complication rates. However, subsequent studies failed to reproduce these results, engendering controversy about the true effectiveness of checklists in real-world settings. This systematic review of 25 studies of the surgical safety checklist found that complication rates decreased with checklist usage in resource-poor settings, but the checklist did not appear to be effective in developed nations. The authors also noted that the reported effect of the checklist was incongruous—in several studies, postoperative complications did not decrease, but postoperative mortality improved, raising questions about what mechanism helped the checklist achieve its effect. These concerns, along with methodological problems in many of the included studies, led the authors to postulate that the observed improvements seen in some studies may have been due to temporal changes or other interventions rather than the checklist itself.
Winters BD, Bharmal A, Wilson RF, et al. Medical care. 2016;54:1105-1111.
The ability to use administrative data to measure patient safety is critical, because chart review is time-consuming and resource-intensive. The AHRQ Patient Safety Indicators (PSIs) and the CMS Hospital-acquired Conditions (HACs) aim to measure and track patient safety using administrative data. PSIs are often used for pay-for-performance, and CMS has a policy of nonpayment for hospitalizations associated with HACs. This systematic review found that PSIs and HACs have not been adequately validated compared to chart review and therefore may be subject to coding error. Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety efforts. These results suggest that unless further development and validation of administrative metrics occurs, widespread implementation of pay-for-performance efforts may not significantly improve patient safety.
Welp A, Meier LL, Manser T. Crit Care. 2016;20(1):110.
Emotional exhaustion is a component of burnout—a critical patient safety issue. Teamwork promotes resilience and thus may protect against burnout and promote patient safety. However, it is unclear how teamwork, burnout, and patient safety interact in a safety culture. This prospective study of critical care interprofessional teams found that clinicians' emotional exhaustion affects teamwork, which leads to worsening clinician reports of patient safety. The authors suggest addressing clinicians' emotional exhaustion prior to team training in order to best augment patient safety in the intensive care unit. A PSNet interview discusses strategies to enhance clinicians' emotional resilience.
Auerbach AD, Kripalani S, Vasilevskis EE, et al. JAMA internal medicine. 2016;176:484-93.
Preventing readmissions is a cornerstone of patient safety efforts. However, one concern about nonpayment for readmissions is that many may not be preventable. To determine whether they were preventable, this observational study investigated readmissions through patient and physician surveys along with chart review. Researchers determined that only one quarter of readmissions were preventable. Factors associated with potential preventability were premature hospital discharge, insufficient communication with outpatient providers, failure to discuss care goals, and emergency department decisions to readmit a patient who did not require a second inpatient stay. These results suggest that multiple interventions will be needed to avert readmissions, and such efforts will have limited impact since most readmissions are not preventable.
Jha A, Pronovost P. JAMA. 2016;315:1831-2.
In this call for better measurement and reporting, two patient safety experts lay out steps that federal policymakers can take to advance patient safety. The commentary emphasizes the need for valid patient safety measures and mentions the Surgeon Scorecard as an example of journalists and private companies stepping in to provide needed transparency. The authors suggest that the Centers for Medicare and Medicaid Services (CMS) focus on measures of the most common causes of iatrogenic harm to hospitalized patients, including adverse drug events, hospital-acquired conditions, and surgical complications. They recommend that CMS remove current metrics that rely on administrative data due to concerns about validity and accuracy of these measures. The commentary advocates for tasking an official agency with defining measurement standards and benchmarks. The authors also propose that Congress fund research on systems engineering. A recent PSNet interview discussed AHRQ's efforts to develop patient safety measures and improvement programs.
Network WG for the CHECKLIST-ICUI and the BR in IC, Cavalcanti AB, Bozza FA, et al. JAMA. 2016;315:1480-90.
Checklists have contributed to some of the most effective patient safety interventions to date, including the landmark Keystone ICU program that nearly eliminated catheter–associated bloodstream infections and the surgical safety checklist that reduced mortality. More recently, checklists have failed to yield improvements in some settings, highlighting that successful programs rely on many external and internal factors beyond checklists. This randomized clinical trial studied the effect of introducing a daily checklist, goal setting, and clinician prompting in intensive care units in Brazil. This robust bundled intervention did not reduce in-hospital mortality. The intervention group showed some improvements in a few process measures, such as use of low tidal volumes, central venous catheters, and urinary catheters, but there was no difference in secondary clinical outcomes. This study adds to the current controversy over the efficacy of checklists for improving patient safety outcomes.
Dreischulte T, Donnan P, Grant A, et al. The New England journal of medicine. 2016;374:1053-64.
Adverse drug events among outpatients are common and can lead to preventable complications. Conducted in primary care practices, this cluster-randomized trial found that a combination of professional education, electronic health record alerts, and financial incentives for practices to review potentially inappropriate prescribing decreased high-risk medication prescriptions. Investigators also observed a decrease in two of the three medication-related complications associated with use of high-risk medications, suggesting a clinical benefit to this intervention. The success of this study argues for similar larger-scale, multi-modal patient safety studies to detect modest but significant improvements.
Riches N, Panagioti M, Alam R, et al. PloS one. 2016;11:e0148991.
Despite increasing focus on diagnostic error, it remains a controversial patient safety issue. The Institute of Medicine recently suggested that further research is needed regarding electronic tools to improve diagnosis. Differential diagnosis generators provide a list of possible diagnoses for a problem. The investigators conducted a systematic review and found that differential diagnosis generators have been shown to improve diagnostic accuracy when a clinician has an opportunity to re-review the case using the software in pre-post studies. The degree of improvement varied between studies. The effect on actual clinician behaviors—such as test ordering, clinical outcomes, and cost—is unclear. Clinicians need prospective studies in order to determine whether such tools enhance diagnosis in actual practice. A recent PSNet perspective discussed future research avenues to ensure progress in diagnostic safety.
Khan A, Furtak SL, Melvin P, et al. JAMA Pediatr. 2016;170(4):e154608.
Whether patient and family understanding of safety issues aligns with standard definitions of medical errors is unclear. In this study, parents of pediatric inpatients were asked if their children experienced any safety incidents during hospitalization. Physician reviewers evaluated parents' reports and designated incidents as errors or quality issues or excluded them. Just under 10% of respondents reported an incident, and 62% of these were confirmed by the study team as medical errors, with the remainder considered either quality issues or exclusions. Consistent with prior studies, many of the confirmed errors were not captured in the medical record. This work demonstrates that allowing patients and families to report safety concerns can identify previously unknown errors. A recent PSNet perspective calls for enhanced patient engagement in safety.
National Quality Forum; NQF.
Health information technology (IT) has transformed health care and improved patient safety, but it has also led to unintended consequences that increase the risk for patient harm. This comprehensive report from the National Quality Forum aims to define and prioritize measures of health IT–related safety so that issues can be quantified and monitored over time. The report identifies nine priority areas for measurement, ranging from tracking the extent of system interoperability to clinical decision support to patient engagement. For each area, the authors recommend using a previously published framework to examine three domains: data considerations like availability and interoperability; technology–work system interaction, such as usability, training, governance, and safety monitoring; and application of health IT to make care safer. The committee proposes to hold health IT vendors, health care organizations, and clinicians accountable for specific safety metrics for health IT systems. Although these measures require further development and testing, this report lays the foundation for more systematically evaluating the safety gains and concerns associated with widespread health IT implementation.
Zuckerman RB, Sheingold SH, Orav J, et al. The New England journal of medicine. 2016;374:1543-51.
The Centers for Medicare and Medicaid Service's policy on nonpayment for certain hospital readmissions has reduced their incidence. However, this policy change may have unintended consequences. One possible outcome is an increased number of patients who return to the hospital being placed on observation status. Comparing readmission rates and observation stays for targeted and nontargeted conditions, this secondary data analysis examined how observation stay rates changed in parallel with readmission rates. The authors found that readmissions decreased, consistent with prior studies, and observation stays increased. Interestingly, a within-hospital analysis determined that the decline in readmissions was not explained by an increase in observation stays. This finding should allay concerns about this specific unintended consequence of the readmission policy, although other issues such as length of stay changes should be addressed.
Vincent C, Amalberti R. New York, NY: SpringerOpen; 2016
Written by two leaders in the patient safety field, Charles Vincent and Rene Amalberti, this book is available for free download on an open access platform. In the preface, the authors say the title reflects the fact that most current safety initiatives are focused on optimizing clinical processes or system improvements, which may succeed in a reasonably controlled environment. However, they sought to show how methods should be aimed at managing risks in the real, complex conditions of health care. The overall approach is oriented around examining safety from the patient's perspective and establishing patient safety as "the management of risk over time." There are separate chapters dedicated to safety strategies in hospitals, home care, and primary care. A prior PSNet interview with Charles Vincent discussed his career as one of the founders of the patient safety movement.