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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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Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374(8):713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Studdert DM, Bismark MM, Mello MM, et al. New Engl J Med. 2016;374(4):354-362.
A growing body of research has begun to assess the role of individual clinicians in patient safety, seeking to identify clinicians whose patients are at elevated risk of adverse events. Examining data on paid malpractice claims from the National Practitioner Data Bank over a 10-year period, this study found that 1% of physicians accounted for 32% of paid claims. Moreover, recidivism was common, in that practitioners with more than 3 claims had a 24% risk of another claim within the next 2 years. As in prior studies of malpractice data, surgeons and obstetricians were more likely to have paid a claim than internists. The pattern of a relatively small number of physicians incurring repeated claims, which mirrors data from studies of patient complaints, implies that it may be possible to identify clinicians who are at high risk of subsequent malpractice claims or patient complaints. The issues around such high-risk physicians are discussed in a previous WebM&M perspective.
Paine CW, Goel V, Ely E, et al. J Hosp Med. 2016;11(2):136-144.
Alarm safety is now a Joint Commission National Patient Safety Goal. This systematic review analyzed 24 studies on alarm characteristics and 8 studies that evaluated interventions to improve alert fatigue. Consistent with other studies, the vast majority of the time, alarms do not signal problems that require clinician action. The most promising intervention strategies for reducing alarms that have emerged thus far are widening alarm parameters, implementing alarm delays, and frequently changing telemetry electrodes and wires. A PSNet perspective discussed approaches to reduce alert fatigue while maintaining safety.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2020;16(2):130-136.
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
Arefian H, Vogel M, Kwetkat A, et al. PloS one. 2016;11:e0146381.
Health care–associated infections are a longstanding patient safety priority, and intensive multifaceted interventions have been shown to prevent them. This systematic review examined economic analyses of interventions to prevent hospital-acquired infections and found highly positive cost–benefit ratios. Although the authors raised concerns that quality of reporting in the identified studies was low, they concluded that preventing hospital-acquired infections is a cost-effective patient safety strategy. A PSNet perspective on the business case for patient safety discussed health care–associated infections.
Larochelle MR, Liebschutz JM, Zhang F, et al. Ann Inter Med. 2016;164(1):1-9.
Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This cohort study examined treatment patterns for patients who had experienced a nonfatal opioid overdose. More than 90% of patients were prescribed opioids following such events, and within 2 years up to 17% of those patients experienced another overdose event. An accompanying editorial notes the lack of systems to ensure clinicians' awareness of patients' opioid overdoses and recommends enhancing training and support so that clinicians are prepared to treat chronic pain and addiction. New approaches are urgently needed given this crisis in medication safety. A previous WebM&M commentary discussed the challenges of prescribing safely for chronic opioid users.
Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222(2):122-128.
Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.
Panesar SS, deSilva D, Carson-Stevens A, et al. BMJ quality & safety. 2016;25:544-53.
Patient safety in ambulatory care settings has received less attention than in the hospital setting, where the patient safety movement originated. This systematic review commissioned by the World Health Organization examined patient safety incidents in primary care. Estimates diverged widely between studies, and most patient safety incidents did not lead to harm. However, the types of incidents most likely to cause harm were missed and delayed diagnoses and medication prescribing problems. The accompanying editorial highlights the need to implement consistent and clear definitions for patient safety incidents and associated harm and advocates for investment in research and improvement efforts for patient safety in primary care.
Shanafelt TD, Hasan O, Dyrbye LN, et al. Mayo Clinic proceedings. 2015;90:1600-13.
Physician burnout can impact patient safety. Prior research has shown that burnout is associated with lower reported quality and safety. This survey study of physicians found that more than half reported one or more symptoms of burnout. In contrast to other adults in the United States, rates of burnout are increasing among physicians. This work adds to the growing calls for addressing the causes of physician burnout. An Annual Perspective discussed burnout among health care professions as it relates to patient safety.
Graber ML, Siegal D, Riah H, et al. Journal of patient safety. 2019;15:77-85.
Although heath information technology (IT) has improved patient safety, studies have shown that implementing electronic health records can introduce new errors. This study examined closed malpractice claims related to health IT. Most cases occurred in ambulatory care settings, suggesting that current health IT may not be optimally designed to support safety in those settings. Cases involving medication errors, diagnostic errors, or treatment complications were almost equally prevalent, indicating that health IT vulnerabilities span multiple tasks and functions. Software design issues and implementation problems also played a role in these incidents. These findings emphasize the need to reexamine health information technologies and how they are implemented in health care systems to enhance safety. A recent PSNet perspective examined challenges in health IT implementation, and another perspective discussed the need for innovations in health IT usability.
Heyland DK, Ilan R, Jiang X, et al. BMJ quality & safety. 2016;25:671-9.
Discordance between patient preferences for end-of-life care and documentation of their wishes is a common problem in hospitals. Such events have been described as silent misdiagnoses and may be classified as medical errors. This audit study across 16 hospitals in Canada quantified how often medical orders for life-sustaining treatments do not match patient preferences. Only 2% of patients who reported a preference for cardiopulmonary resuscitation (CPR) had CPR withheld in their medical orders; whereas, 35% of patients who wished to forgo CPR had orders to receive it in the event of an arrest. This mismatch represents a considerable source of potential overtreatment, which may result in numerous adverse downstream effects. A previous WebM&M commentary discussed tools for eliciting end-of-life preferences.
McGlynn EA, McDonald KM, Cassel CK. JAMA. 2015;314(23):2501-2502.
Measurement in patient safety is challenging and requires consensus to determine the presence of specific problems. In light of recommendations from the Improving Diagnosis in Health Care report, this commentary reviews five purposes for measuring diagnostic errors: determining the extent of diagnostic errors; understanding their underlying causes; measuring whether interventions work; skill assessment for training and education; and tracking performance. The authors describe how achieving each of these goals will require distinct strategies. A PSNet interview with Hardeep Singh discussed issues of measurement in diagnosis.
Agency for Healthcare Research and Quality; AHRQ.
Hospital-acquired conditions (HACs), some of which are never events, have been an important focus of patient safety initiatives, with reporting requirements and Medicare nonpayment leading to significant efforts to prevent these conditions. This update to a prior report from AHRQ details and confirms the declining rates in HACs between 2010 and 2013. The analysis indicated that hospitalized patients experienced 1.3 million fewer HACs over the 3 years (2011–2013) than if the HAC rate had remained at the 2010 level. Consequently, the report estimates a $12 billion savings in health care costs and 50,000 fewer hospital patient deaths. These improvements coincided with nationwide efforts to reduce adverse events, such as the Partnership for Patients initiative and Medicare payment reform. The remaining burden of HACs suggests continued investment in this patient safety problem is needed.
Jena AB, Schoemaker L, Bhattacharya J, et al. BMJ (Clinical research ed.). 2015;351:h5516.
Defensive medicine—the practice of performing potentially unnecessary procedures or diagnostic tests to avoid the threat of malpractice liability—is thought to contribute to high health care costs in the United States. Because procedures and tests carry risks of complications, defensive medicine also may lead to adverse events. This secondary data analysis examined prospectively whether physicians who performed more cesarean deliveries (considered to be defensively motivated) were more or less likely to be subject to malpractice claims compared with those performing fewer cesarean deliveries. Researchers adjusted for available clinical characteristics and still found that obstetricians who performed more cesarean deliveries were less likely to have subsequent alleged malpractice incidents. This finding suggests that defensive medicine may be a rational physician response to the current malpractice environment, and underscores the patient safety rationale for malpractice reform. A previous WebM&M commentary discusses the causes and consequences of defensive medicine.
Singh H, Graber ML. New Engl J Med. 2015;373(26):2493-2495.
Diagnostic error received relatively little attention until more recently and is now widely recognized as a major source of patient harm. The National Academy of Medicine (NAM) report, Improving Diagnosis in Health Care, estimated that most United States adults will experience one or more diagnostic errors in their lifetimes. Summarizing the goals from the report, this commentary details how the recommendations from the NAM can lead to enhanced diagnostic safety. The authors also acknowledge potential challenges to implementing the systems and process changes described. An Annual Perspective discussed advances in the field of diagnostic error.
Eguale T, Buckeridge DL, Verma A, et al. JAMA Intern Med. 2016;176(1):55-63.
Prescribing medications for indications that are not approved by the Food and Drug Administration—so-called off-label prescribing—is common. Although it is invariably well-intentioned, this population-based study demonstrates that off-label prescribing is a risk factor for medication errors. The study used the electronic medical record in Quebec that required physicians to enter the reason for prescribing or discontinuing medications to analyze the frequency of off-label prescribing and adverse events associated with this practice. Off-label prescribing was associated with a higher adverse drug event risk, especially when there was no convincing scientific indication for the unapproved use (which was the case in more than 80% of off-label prescriptions). The accompanying editorial notes that the FDA is under pressure to relax restrictions on marketing of drugs for off-label purposes and raises the concern that eliminating such restrictions could expose more patients to adverse events.
Geller AI, Shehab N, Weidle NJ, et al. The New England journal of medicine. 2015;373:1531-40.
Dietary supplements can cause harm, especially in combination with prescribed medication, and their use is increasing. This report from an established surveillance system sampled emergency department visits related to dietary supplements. The results suggest that adverse events related to dietary supplements cause 23,000 emergency department visits per year in the United States. Ingestions by unsupervised children accounted for nearly a quarter of the visits. Other common events included palpitations, chest pain, or tachycardia related to weight loss or energy supplements. The authors note that there is no legal requirement for supplement manufacturers to identify potential adverse effects on the products themselves, and they encourage clinicians to educate patients about potential adverse reactions.
Nanji KC, Patel A, Shaikh S, et al. Anesthesiology. 2016;124:25-34.
Medication errors in the hospital have been studied, quantified, and systematically evaluated for potential solutions. A notable exception is the perioperative setting, where medications given by anesthesiologists often bypass standard safety checks. This study is the largest prospective observational study of anesthesia-related medication events available to date. At least one medication error or adverse drug event occurred in nearly half of the 277 operations observed. Approximately 1 in 20 perioperative medication administrations resulted in a medication error or adverse drug event; 80% of these errors were deemed preventable. None of the errors resulted in death, but 2% were considered life-threatening. There were no differences in event rates among resident physicians, nurse anesthetists, and staff anesthesiologists. The study took place at an academic hospital with substantial local expertise in medication safety, where operating rooms already used a barcode-assisted syringe labeling system. An accompanying editorial suggests that medication error rates may therefore be even higher in other settings and community hospitals.
Harrison R, Walton M, Manias E, et al. International journal for quality in health care : journal of the International Society for Quality in Health Care. 2015;27:424-42.
Patient perspectives are critical to inform patient safety efforts. This systematic review identified studies of patient experiences with adverse events. Included studies demonstrate that the types of adverse events patients most often identify are medication errors and suboptimal communication, and that patient demographic characteristics influence the likelihood of reporting these events. Calling for increased use of patient experiences in future studies, the authors suggest that investigations into adverse events are incomplete if patient perspectives are not included. These results demonstrate the ongoing need to enhance patient engagement in safety research. A previous AHRQ WebM&M perspective delves further into engaging patients in safety improvement.
Maben J, Griffiths P, Penfold C, et al. BMJ quality & safety. 2016;25:241-56.
This study used robust research methods to examine the expected and unanticipated effects of moving to all single-occupancy inpatient rooms. The accompanying editorial points out that on the surface this seems like a common sense intervention likely to improve patient experience and safety. However, this study demonstrates the complex effects even seemingly straightforward interventions can create. Although two-thirds of patients preferred the single rooms, some patients felt more isolated and lonely. Staff expressed concerns about worsened visibility, surveillance, teamwork, and monitoring. In addition, staff workflows had to change significantly and their hourly walking distances increased substantially. There was no evidence that single rooms reduced infections. Although fall rates increased following the move, the researchers felt that based on the patterns and comparison to the control hospital, this may not have been attributable to the single rooms. As the editorial highlights, this study supports the importance of vigorously evaluating a range of impact measures, including quality, safety, costs, and staff and patient experiences.