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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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Lawton R, O'Hara JK, Sheard L, et al. BMJ quality & safety. 2015;24:369-76.
Patient engagement programs are being widely implemented as means of improving the safety and quality of hospital care, and prior studies have shown that patients can identify safety issues that go undetected by other methods. This study examined the relationship between patient and staff perception of safety and overall safety outcomes by comparing patient perceptions of safety (measured by the Patient Measure of Safety survey), staff perception of safety (measured by the AHRQ Hospital Survey on Patient Safety Culture), and quantitative measures of patient safety events (measured by the NHS Safety Thermometer). The investigators found that both Patient Measure of Safety and Hospital Survey of Patient Safety Culture results were correlated with objective measures of safety, and they appeared to contribute independently to predicting safety outcomes. This study provides further evidence for including patient perspectives in identifying and measuring safety issues.
Adler L, Yi D, Li M, et al. Journal of patient safety. 2018;14:67-73.
A 2013 study showed hospitals actually profit when patients experience surgical complications, calling into question the business case for patient safety. This large multistate study used the Institute for Healthcare Improvement's global trigger tool to examine how all-cause inpatient harms affect hospital finances and clinical outcomes. Approximately 13% of inpatients experienced temporary harm and 12% experienced harm. This study relied on complicated cost accounting and statistical modeling, ultimately using three different financial models, including a novel approach that accounts for various diagnosis-related groups, to analyze the results. Patients who experienced harm had increased total costs, variable costs, and length of stay. Also, harms were associated with a lower contribution margin—an indicator of a hospital's profitability—suggesting harms result in negative financial outcomes for hospitals. As payment models increasingly shift toward paying for value rather than volume, the negative financial effects of inpatient harms are likely to be heightened.
Wen T, Attenello FJ, Wu B, et al. J Hosp Med. 2015;10(7):432-438.
Whether the "July effect"—a period of increased risks due to the introduction of new interns and residents at hospitals—is a real phenomenon or merely a myth has been long debated. Prior studies have largely been mixed, although a systematic review concluded that the weight of the evidence suggests increased mortality during this annual workforce transition. This retrospective cohort study used the AHRQ-maintained nationwide inpatient sample database to examine hospital-acquired conditions, which are considered to be never events. Of the nearly 145 million admissions recorded across 4 years, hospital-acquired conditions occurred in 4.7% of hospitalizations overall, while patients admitted in July had an incidence of 4.9%. July admissions were linked to a 6% increased likelihood of experiencing a hospital-acquired condition, with multivariate analysis corrections. Hospital-acquired conditions, which represent preventable complications, are likely a more sensitive marker for hospital quality and safety than mortality. A prior AHRQ WebM&M commentary explored the implications of the July effect through discussing a case of iatrogenic hypoglycemia (a never event) related to a new intern's lack of experience.
Wachter R. New York, NY: McGraw-Hill; 2015. ISBN: 9780071849463.
Over the past few years, driven by $30 billion of federal incentives to doctors and hospitals, the adoption rate for electronic health records has dramatically increased, from approximately 10% in 2008 to 70% today. In essence, health care has switched from being a primarily analog to a primarily digital industry. While evidence suggests that the digitization of health care is having a positive effect on safety and quality, many challenges and unanticipated consequences have emerged. Written by a national leader in patient safety, this book chronicles some of these, including physician dissatisfaction, changing relationships among providers and between providers and patients, new kinds of medical mistakes, and problems with clinician work flow. It also highlights some of the opportunities arising from increasingly engaged patients and the entry of Silicon Valley into the health care market. Ultimately, it paints a hopeful picture of where health care information technology may take us, making the case that this positive future state will depend on both the evolution of the software and on changes in culture, training, and the organization of the work.
Elmore JG, Longton GM, Carney PA, et al. JAMA. 2015;313:1122-32.
Microscopic review of biopsy tissue is considered the gold standard for diagnosis of cancer and other diseases, but prior research has shown a small yet consistent rate of errors in cancer diagnosis that is attributable to misinterpretation of biopsy specimens. This study sought to quantify error rates in breast cancer diagnosis by having a broad sample of pathologists review a standardized set of biopsies whose diagnoses had been established by expert clinicians. Although biopsies with cancer were diagnosed very accurately, specimens with atypia (abnormal tissue that may be pre-cancerous) had substantial variability, with pathologists tending to overdiagnose these specimens (i.e., ascribe a diagnosis of cancer or pre-cancerous lesions when the correct diagnosis was benign). The authors caution that the specimens used in this study were intentionally chosen to be relatively difficult to interpret, and this may have resulted in overestimating the error rate. A related editorial notes that while the overall rate of diagnostic error in this study was low, misdiagnosis of atypia does have important prognostic and treatment significance for women, and therefore pathologists should systematically consult with colleagues in difficult cases, and more advanced molecular diagnostic methods should be applied in order to reduce subjectivity in biopsy interpretation.
Austin M, Jha AK, Romano PS, et al. Health Affairs (Project Hope). 2015;34(3):423-430.
One strategy to improve patient safety is public reporting of performance data, and hospital quality ratings have proliferated. In this study, researchers examined the extent of agreement among hospital ratings issued by U.S. News & World Report, HealthGrades, The Leapfrog Group, and Consumer Reports. Each rating system has a different emphasis, varying inclusion and exclusion criteria, and focuses on different measures of quality. There is very little agreement among the ratings for either high or low performance—not one hospital was rated as a top performer across all four ratings—which makes these ratings challenging for consumers to interpret or use in decision making. These findings are consistent with prior work demonstrating variability in surgical quality rankings. The authors call for transparency in how ratings are constructed and clear communication with consumers to facilitate informed decisions regarding their care. A recent AHRQ WebM&M interview with Leah Binder, President and CEO of The Leapfrog Group, explored the development of the Hospital Safety Score and Leapfrog Hospital Survey.
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414.
According to Weick and Sutcliffe, high-reliability organizations operate under challenging conditions yet experience fewer problems than would be anticipated as they have developed ways of "managing the unexpected" better than most organizations. The authors, professors at the University of Michigan School of Business, use both case studies and theory-based analysis to explain the methods that result in organizational mindfulness, and, through it, a more robust culture of safety. This third edition of their classic text provides individual chapters on each of the five elements of high reliability and pays increased attention to the roles of interaction, sensemaking, and language in achieving more reliable performance under risky conditions.
Merkow RP, Ju MH, Chung JW, et al. JAMA. 2015;313(5):483-495.
Hospital readmissions have received intensive focus lately, largely compelled by Medicare's expanded financial penalties for excessive readmission rates. This study reviewed 30-day readmissions following surgery at hospitals enrolled in the National Surgical Quality Improvement Program. Nearly half a million operations were included, with an overall readmission rate of 5.7%. Following lower extremity vascular bypass, approximately 1 in 7 patients were readmitted. Surgical site infections accounted for the largest proportion of overall readmissions. It is notable that only 2% of patients were readmitted for the same complication that prompted their index admission, further confirming that surgical readmissions are overwhelmingly due to new complications arising from the procedure. In an accompanying editorial, Dr. Lucian Leape notes that analyses of these surgical complications can serve as "treasures" for providing important lessons for improvement, and he calls for a 50% reduction in surgical complication rates in the near term.
Osborne NH, Nicholas LH, Ryan AM, et al. JAMA. 2015;313:496-504.
This large study used 9 years of national fee-for-service Medicare data to examine differences in surgical outcomes between hospitals participating in the National Surgical Quality Improvement Program (NSQIP) and nonparticipating hospitals. There was no statistically significant difference in the rate of improvement for any of the measured outcomes—risk-adjusted 30-day mortality, serious complications, reoperation, or 30-day readmissions—at 1, 2, or 3 years after enrollment in NSQIP versus well-matched controls. Notably, over 6 years there has been a trend toward reductions in mortality, serious complications, and readmissions across hospitals, regardless of NSQIP participation. The results of this study strengthen those of the study by Etzioni and colleagues in the same issue of the Journal of the American Medical Association. In an accompanying editorial, Dr. Donald Berwick states, "it is implausible to conclude that knowing results is not useful—perhaps essential—for systematic improvement of outcomes," but that hospitals must realize measurement alone is insufficient.
Magrabi F, Baker M, Sinha I, et al. International journal of medical informatics. 2015;84:198-206.
Health information technology can both improve patient safety and introduce risks. This analysis examined all safety events associated with the United Kingdom's national program for health information technology. The researchers found that while most events were technical failures, incidents involving human errors had a higher chance of causing harm to patients. Technical failures affecting 10 or more patients accounted for nearly 25% of events and were more likely to impact care delivery. These results underscore the concerns in prior reports about the unintended consequences of implementing health information technology on patient safety. The findings also lend weight to the Institute of Medicine recommendations that errors related to health information technology be reported and investigated in the United States. A past AHRQ WebM&M perspective explored the promised benefits of health information technology alongside the challenges of implementation and idiosyncrasies of available systems.
Reames BN, Krell RW, Campbell DA, et al. JAMA surgery. 2015;150:208-15.
Initial enthusiasm for the role of checklists in reducing perioperative complications has been tempered by subsequent studies that did not replicate the safety improvements. This study evaluated the effect of the Keystone Surgery program, which combined an evidence-based checklist and the comprehensive unit-based safety program to enhance safety culture. Comparison of Keystone Surgery hospitals to those that did not implement the intervention found no differences in outcomes (including surgical site infections and 30-day mortality) between groups. The investigators acknowledge that many participating sites lacked the infrastructure to collect and regularly feed back performance data to frontline providers, which may have limited the effectiveness of the intervention. The study adds to a growing body of literature that emphasizes the role of effective implementation and monitoring in ensuring the success of checklist-based interventions. A past AHRQ WebM&M interview and perspective explore the development and use of checklists to augment safety in health care.
Schiff GD, Amato MG, Eguale T, et al. BMJ quality & safety. 2015;24:264-71.
This study used a two-stage approach to analyze the effectiveness of computerized provider order entry (CPOE) at preventing medication errors in real-world settings. The investigators analyzed data from the MEDMARX database in order to identify the types of medication errors caused by computerized order entry. From these data, the researchers developed 21 examples of problematic orders and tested whether they could be entered in a range of commercial CPOE systems. The majority of orders were entered successfully and quickly, without the CPOE system generating any alerts or requiring clinicians to use only minor workarounds to enter the order. Even when the CPOE system did generate an alert, these could generally be overridden by clinicians without changing the order. The study findings mirror those of a prior simulation study and highlight the importance of real-world usability testing for health information technology. Although CPOE systems have been shown to reduce prescribing errors, this study's results indicate that the safety benefits of CPOE may not be achieved without careful implementation and ongoing evaluation.
Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-84.
This observational study analyzed surgical outcomes before and after 2011 ACGME duty hours reform using data from the American College of Surgeons National Surgical Quality Improvement Program. Researchers applied difference-in-differences analysis, which can account for some of the uncertainty of nonrandomized data, a common concern in patient safety research. They assessed changes in surgical mortality and complication rates before and after implementation of duty hours restrictions in teaching hospitals. The authors compared this difference with mortality and complication rates during the same time period in nonteaching hospitals. Any variation between teaching and nonteaching sites could be attributed to the effects of duty hours, since the authors accounted for case mix and comorbidities. No differences in patient outcomes were observed, adding to the evidence that duty hours restrictions do not improve patient outcomes. Researchers also found no change in trainee examination scores, despite concerns that duty hours adversely impact trainee education. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.
Patel MS, Volpp KG, Small DS, et al. JAMA. 2014;312:2364-73.
This observational study sought to determine whether the ACGME 2011 duty hour reforms led to changes in 30-day mortality or readmissions for several medical diagnoses—acute myocardial infarction, stroke, acute gastrointestinal bleed, or congestive heart failure—and for general, orthopedic, or vascular surgery. The authors examined how hospital teaching status, which they defined using resident-to-bed ratio, affected outcomes for these conditions. This measure provides insight into the intensity of teaching at a given institution rather than defining each hospital as teaching versus nonteaching. During the study time period, although readmissions and mortality both declined overall, this decrease did not differ based on teaching status, suggesting that the improvement in readmissions and 30-day mortality is not attributable to duty hour reform. These results are consistent with prior work following the 2003 duty hour reforms which has failed to demonstrate benefit to patient outcomes from costly duty hour reforms. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.
Chassin MR, Mayer C, Nether K. Joint Commission journal on quality and patient safety. 2015;41:4-12.
Although appropriate handwashing has been identified as an essential factor in preventing health care–associated infections, hand hygiene rates remain unacceptably low at many hospitals. This quality improvement project aimed to achieve adherence to hand hygiene practices at eight hospitals using change management methods drawn from human factors engineering. Each hospital investigated and identified specific causes of noncompliance with handwashing and developed specific interventions to address these barriers. These individualized efforts yielded a significant improvement in handwashing behavior. The authors argue that allowing each site to tailor the intervention to the specific causes of noncompliance led to the sustained improvements. This study suggests that local improvement may be a fruitful method to enhance the proven but incompletely implemented practice of hand hygiene. A recent AHRQ WebM&M interview and perspective discuss ways to enhance hand hygiene adherence.
Agency for Healthcare Research and Quality; AHRQ.
This report from the Agency for Healthcare Research and Quality provides estimates on hospital-acquired conditions (HACs)—including never events and health care–associated infections—for hospitals in the United States from 2010 to 2013. These adverse events continue to decline steadily, with an estimated 9% decrease in most recent year over year comparison. In 2013, there were 121 HACs for every 1000 hospital admissions. These improvements resulted in significant cost-savings and reduced morbidity and mortality rates. The authors attribute this change to CMS payment reform and to the Partnership for Patients initiative. Although uncertainty about the cause of these improvements remains, the lower HAC rate clearly demonstrates that efforts to reduce patient safety problems in hospitalized patients are yielding results. The substantial remaining burden of HACs argues for more investment in patient safety in hospital settings.
Dai H, Milkman KL, Hofmann DA, et al. The Journal of applied psychology. 2015;100:846-62.
This large observational study demonstrated that hand hygiene compliance rates decrease over the course of a normal work shift. During the first hour of work, average compliance rates were approximately 43%. This dropped to 35% for the last hour of a 12-hour shift. In addition, more intense work shifts were associated with even bigger hand hygiene compliance drop-offs. The authors extrapolate these results to estimate that this compliance decrement could produce an additional 600,000 infections per year in the United States, resulting in up to 35,000 unnecessary deaths and $12.5 billion in excess costs. More time off between shifts led to better compliance rates during a subsequent shift. In this sample, 65% of the caregivers were nurses, and only 4% were physicians. Longer nursing shifts have previously been linked to other patient safety hazards. A prior AHRQ WebM&M commentary discussed challenges related to nursing staffing.
Srigley JA, Furness CD, Baker R, et al. BMJ Qual Saf. 2014;23(12):974-980.
Hand hygiene is a core practice for decreasing health care–associated infections, but achieving compliance has proven difficult. In this study, hand hygiene rates were about threefold higher when an auditor was present compared with hallway dispensers that were not visible by a direct observer. Since many publicly reported hand hygiene rates are based on direct auditor observations, this study suggests these metrics may be greatly inflated and unreliable. A prior WebM&M perspective reviewed recent strategies for promoting and monitoring hand hygiene.
Sittig DF, Classen DC, Singh H. J Am Med Inform Assoc. 2015;22:472-8.
The Institute of Medicine and the Food and Drug Administration have called for the establishment of a national organization to oversee health information technology (IT) safety in the United States. This commentary, written by leaders in the IT field, recommends goals for the proposed Office of the National Coordinator-based Health IT Safety Center, including monitoring and tracking safety events, investigating incidents and disseminating guidance, building a process and infrastructure to examine the safety of health IT systems, and generating support for vigilance around health IT safety in the public and private sectors. The authors also highlight the convening ability of such a center as a critical component for transforming the safety of health IT.
Drew BJ, Harris P, Zègre-Hemsey JK, et al. PloS one. 2014;9:e110274.
Alarm fatigue, in which clinicians ignore safety alerts if they are too frequent or perceived to be clinically irrelevant, can lead to lack of awareness of an unsafe situation. This concern is particularly acute in intensive care units where patients are typically monitored with multiple devices, each with alarms. This retrospective review examined all alarm data regarding physiologic monitoring, including electrocardiogram, blood pressure, and oxygenation, from five intensive care units in a medical center. The vast majority of alarms were false-positives. Inappropriate alarm settings, electrode failure leading to poor signal quality, and alerts for non-actionable events were common causes for unnecessary alarms. The authors call for improving device design and monitor algorithms in order to reduce alarm fatigue. A previous AHRQ WebM&M perspective discussed the safety of medical devices.