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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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Riskin A, Erez A, Foulk TA, et al. Pediatrics. 2015;136:487-95.
Disruptive physician behavior is a recognized patient safety problem. Fear of confrontation with a disruptive individual may inhibit speaking up about potential errors and worsen safety culture and teamwork. In this simulation study, neonatal intensive care unit teams were exposed to either rude or neutral comments from an observer during their assigned simulated task. Compared to teams receiving neutral comments, those who were exposed to rudeness performed worse. This study complements prior studies which document perceived consequences of disruptive behavior by demonstrating worse simulated task performance. This work also reveals that rudeness external to a team can affect performance and suggests that a polite work culture would foster patient safety.
Khullar D, Jha AK, Jena AB. N Engl J Med. 2015;373(26):2491-2493.
Diagnostic error has recently garnered attention as a patient safety problem, as evidenced by the publication of a major report on the topic by the Institute of Medicine. This commentary describes why diagnostic errors previously received less attention than other safety efforts and highlights the importance of addressing this issue. The authors emphasize that diagnostic errors have become even more important in light of the growing clinical and financial costs of these errors in health care. They recommend strategies to improve diagnosis, such as establishing a formal curricula for educating trainees about misdiagnosis and developing validated metrics to determine how frequently diagnostic errors occur and understand their downstream health and economic implications.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Wolf M, Krause J, Carney PA, et al. PloS one. 2015;10:e0134269.
Collective intelligence encompasses several methods for summarizing input from multiple individuals, which can often be more accurate than any one expert. In this study, investigators applied several collective intelligence algorithms to mammography interpretation. They found that aggregating the interpretations of multiple radiologists resulted in higher accuracy—fewer false positive results and more true positive results—than even the most accurate single radiologist. This work builds on earlier studies of diagnostic accuracy in imaging studies. This study has profound implications for improving diagnosis through collaboration between clinicians in real time, perhaps facilitated through technology, as a complement to the long-standing diagnostic safety strategy of morbidity and mortality conferences, which provide group feedback once a case has concluded.
Murphy DR, Wu L, Thomas EJ, et al. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2015;33:3560-7.
Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.
Verghese A, Charlton B, Kassirer JP, et al. Am J Med. 2015;128(12):1322-4.e3.
There is a growing concern that lack of emphasis on performing the physical examination will lead to diagnostic errors. This study asked physicians to report cases of oversights in the physical examination which contributed to missed or delayed diagnosis. The majority of incidents reported were errors of omission in which the entire examination was not performed, with smaller proportions reporting misinterpretation or failure to conduct a specific aspect of the examination. Respondents reported delays and failures in diagnosis as well as significant instances of over-treatment and increased cost. This underscores the need to emphasize the importance of the physical examination in medical education and practice as a patient safety strategy. The lead author, Dr. Abraham Verghese, discussed the importance of physical examination in a past AHRQ WebM&M interview.
Govindarajan A, Urbach DR, Kumar M, et al. The New England journal of medicine. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Haut ER, Lau BD, Kraus PS, et al. JAMA surgery. 2015;150:912-5.
Prevention of hospital-acquired venous thromboembolism (VTE) is a strongly recommended patient safety practice. This retrospective review of hospital-acquired VTE at one tertiary care hospital found that many patients who developed VTE while hospitalized were prescribed appropriate prophylaxis but did not receive all of the prescribed doses. The authors point out that since current quality metrics measure only prescription of VTE prophylaxis and not actual administration, they may overestimate hospital performance on this safety issue. Moreover, nearly half of the patients with VTE had received prophylaxis that is currently considered optimal, an important finding since VTE is often referred to as a "preventable adverse event."
Tsai TC, Jha AK, Gawande AA, et al. Health Aff (Millwood). 2015;34(8):1304-1311.
Hospital leadership can play a critical role in improving safety and quality, as highlighted in a 2009 Joint Commission sentinel event alert. A prior review found that the governance boards of high-performing hospitals had greater engagement in safety activities compared to low-performing hospitals. However, the mechanisms by which hospital management can improve safety and quality remain undefined. This study, which used survey data from a large sample of hospitals in the United States and England, advances knowledge in this area by defining the key characteristics of management and boards at high-performing hospitals. The investigators found that compared to hospitals that scored poorly on quality metrics, high-performing hospital boards paid more attention to quality and explicitly used quality metrics to assess management performance. In addition, high-performing hospitals used more effective management practices, i.e., they consistently set quality targets and had a greater focus on hospital operations. Hospitals with high management scores were also more likely to be teaching institutions. As many hospital boards still do not prioritize patient safety, these results help identify management practices that could be implemented to help improve safety and quality at the hospital level. One health system's approach to leadership emphasis on quality and safety is discussed in a past AHRQ WebM&M perspective.
Hogan H, Zipfel R, Neuburger J, et al. BMJ (Clinical research ed.). 2015;351:h3239.
Challenges in measuring hospital quality persist despite multiple public efforts. A commonly used measure of hospital quality is all-cause mortality. In this study, researchers examined whether two measures of the standardized mortality ratio, which represent differences from expected mortality, are associated with avoidable deaths, defined as those deaths linked to errors. Adjudicators found that less than 5% of deaths were avoidable, and that this proportion was not associated with hospitals' standardized mortality ratios. The authors conclude that the standardized mortality ratio is unlikely to reflect hospital quality, and argue for using condition-specific indicators focused on severe conditions with well-established care pathways. A previous AHRQ WebM&M interview explored the development of hospital standardized mortality ratios and their role in monitoring safety and quality.
Semigran HL, Linder JA, Gidengil C, et al. BMJ. 2015;351:h3480.
There is concern around patients' increasing use of online symptom checkers for medical information and health care recommendations. This study used standardized patient cases to examine the accuracy of 23 publicly available services which aim to provide a diagnosis for specific symptoms or give a triage recommendation. The online services listed the correct diagnosis first in about one-third of instances and listed the correct diagnosis in the top 20 possible diagnoses in more than half of cases. Concerningly, symptom checkers provided varying triage recommendations, with appropriate advice ranging from 33% to 78% of evaluations. Certain symptom checkers encouraged users to seek care in cases where self-care was reasonable. These data do not support the use of online symptom checkers for diagnosis or triage and argue for use of simulation approaches to evaluate digital health tools. A related editorial calls for evidence on the actual use of such symptom checkers, followed by randomized trials to evaluate the effect on outcomes and costs prior to their widespread implementation.
Baines R, Langelaan M, de Bruijne M, et al. BMJ Qual Saf. 2015;24(9):561-571.
This retrospective study in the Netherlands encompasses three national major adverse event studies. These authors previously reported that the adverse event rate in the Netherlands had increased between 2004 and 2008. In this current study, there was no change in overall adverse event rates in 2011/2012 compared to 2008, while preventable adverse events were markedly reduced by 45%. Following multiple adjustments, this decrease was still evident (30%), though no longer met statistical significance (p=0.10). The decreased harms were seen in areas addressed by national safety programs implemented during this time, suggesting a positive effect from these efforts. A related editorial by Charles Vincent and Rene Amalberti discusses the expanding scope of patient safety as more medical harms become regarded as preventable. A second editorial by two of the journal's editors discusses the degree to which the nonsignificant reduction in preventable adverse events plausibly represents improvements from a national patient safety program in the Netherlands. It also advances the idea that the results highlight some of the limitations of adverse events as a measure of progress in patient safety, a point also made in the editorial by Vincent and Almaberti.
Szymczak JE, Smathers S, Hoegg C, et al. JAMA Pediatr. 2015;169(9):815-821.
Health care workers often work while sick. This phenomenon, known as "presenteeism," has been implicated in outbreaks of health care–associated infections and is associated with burnout. Researchers surveyed physicians and advanced practice clinicians at a children's hospital. This study found that most clinicians reported working while sick, consistent with a prior study of presenteeism among resident physicians. Cultural and system factors resulted in pressure to work while ill, including a sense of not wanting to let colleagues or patients down by being absent and lack of support systems to provide coverage for sick clinicians. The accompanying editorial acknowledges the stigma that clinicians face if they take sick leave and calls for organizations to develop transparent and equitable policies and systems to combat presenteeism.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;158:515-21.
Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event. Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Southwick FS, Cranley NM, Hallisy JA. BMJ quality & safety. 2015;24:620-9.
This study analyzed data from an internet-based reporting system that enabled patients and families to describe adverse events. Respondents reported missed and delayed diagnoses, treatment errors, procedural complications, health care–associated infections, and adverse drug events. Most participants did not experience prompt error disclosure but instead faced a denial of responsibility and secretive behavior, which they related to subsequent mistrust. To prevent adverse events, patients and family members suggested using systems approaches (such as universal handwashing and other infection control measures), improving care transitions between providers, ensuring supervision of trainees, and partnering with patients and families for shared decision-making. These findings underscore the importance of error disclosure, effective communication, and allowing patients to report adverse events in order to enhance safety.
Pannick S, Davis R, Ashrafian H, et al. JAMA internal medicine. 2015;175:1288-98.
Interdisciplinary team care interventions are increasingly common on medical wards, based partly on a widespread belief that these practices will improve efficiency and patient safety. This systematic review sought to evaluate the performance of hospital-based interdisciplinary teams on patient outcomes. The majority of studies have chosen length of stay, complications, readmission, or mortality rates as their primary outcomes, but interdisciplinary teams rarely seem to affect these traditional quality measures, which may be insensitive to teamwork improvements in care delivery. The authors call for establishing more relevant outcomes to evaluate interdisciplinary team interventions. An accompanying commentary notes that this systematic review provides an opportunity to highlight the potential harms of choosing the wrong metrics to evaluate an intervention, which can undermine a program's mission.
Dhalla IA, O'Brien T, Morra D, et al. JAMA. 2014;312:1305-12.
Preventing hospital readmissions has been a major health system priority for several years. Although recent data indicates that readmissions in adult patients are decreasing slightly, the approaches individual hospitals or health systems should use to prevent readmissions remain unclear. This randomized controlled trial evaluated the effect of a postdischarge virtual ward where patients received postdischarge care from a multidisciplinary team that met daily to review the patient's progress, conduct home visits, arrange home services, and coordinate care with the patient's primary physicians. Patients were admitted to the virtual ward for a mean of 35 days after discharge and received 3 home visits on average during that time. Despite the intensity of the intervention, there was no effect on 30-day readmissions or any other clinical outcome compared to usual postdischarge care. Another recent randomized trial found that a similarly intensive intervention did not reduce readmissions in a vulnerable elderly patient population. The authors of this study note that difficulty in communicating with primary care physicians, exacerbated by the lack of an integrated electronic medical record, may have contributed to the failure of the virtual ward at preventing readmissions.
Haugen AS, Søfteland E, Almeland SK, et al. Annals of surgery. 2015;261:821-8.
Initial enthusiasm about the ability of the World Health Organization's surgical safety checklist to prevent harm was tempered by a subsequent study that failed to improve clinical or safety outcomes. The conflicting results of surgical checklist studies have led to concerns that checklists may lack effectiveness when care is of relatively high quality at baseline, and that poor implementation can hinder their use. In this study, the WHO checklist proved successful at improving safety outcomes when implemented across five surgical services at two academic hospitals in Norway. The checklist's success in this rigorously designed and analyzed study was likely attributable to the institution having followed a structured implementation process that had been previously demonstrated to improve safety culture in the operating room. The controversy around surgical safety checklists is discussed in a recent AHRQ WebM&M interview.
Stockwell DC, Bisarya H, Classen DC, et al. Pediatrics. 2015;135:1036-42.
Trigger tools are widely used as a means of detecting adverse events, but most of the existing triggers were developed and validated in adult populations. This study reports on the validation of a trigger tool for hospitalized pediatric patients, based on the Institute for Healthcare Improvement's Global Trigger Tool. In a retrospective chart review across six academic children's hospitals, the tool identified harm in 40% of admissions—a proportion comparable to a similar study in adult inpatients. Nearly half of these incidents were considered preventable. Other studies using slightly different pediatric trigger tools have found a lower incidence of adverse events. The use of trigger tools was discussed in a previous AHRQ WebM&M perspective.
Attenello FJ, Wen T, Cen SY, et al. BMJ. 2015;350:h1460.
Never events are preventable adverse events which often trigger accreditation concerns and for which hospitals cannot be reimbursed by Centers for Medicare and Medicaid Services (CMS). This study used nationwide hospital discharge data to identify never events and examined whether the weekend effect—more frequent adverse events outside of standard working hours compared to the usual work week—was present for never events. Researchers found a 2% higher incidence for weekend admissions compared to weekday admissions; after adjustment for patient and hospital factors, this difference was further magnified. This data adds to prior work on the weekend effect to demonstrate that current weekend hospital conditions are associated with higher risk of serious and preventable hospital-acquired conditions. A related editorial highlights the need for constant vigilance and a universal approach for preventing never events rather than a specific focus on weekend work.