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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.


The “Emerging Classics” designation identifies those resources that may not have met the level of a “Classic” yet due to limited citation in the published literature or in the level of impact/contribution to the environment, but these are resources which our patient safety subject matter experts believe have the potential to drive change in the field.

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 pragmatic,... Read More

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Patel P, Martimianakis MA, Zilbert NR, et al. Acad Med. 2018;93:769-774.
Semi-structured interviews of 15 surgical residents revealed that surgical trainees may feel pressured to exhibit certain characteristics they perceive as consistent with the ideal surgical personality. The authors suggest that trainee education should acknowledge the impact of the sociocultural context of the surgical environment on trainees.
Bajaj K, Minors A, Walker K, et al. Simul Healthc. 2018;13:221-224.
Frontline simulations offer valuable opportunities to explore system issues, process weaknesses, and teamwork skills. This article discusses risks associated with in situ simulations and describes how to determine when simulations should be canceled, postponed, or relocated to ensure safety.
Finn KM, Metlay JP, Chang Y, et al. JAMA Intern Med. 2018;178(7):952-959.
Over the past decade, with the goal of improving both the educational experience and patient safety, the Accreditation Council for Graduate Medical Education has introduced regulations restricting resident duty hours and requiring graded supervision by faculty physicians. While many studies have evaluated how duty hour restrictions influence safety outcomes, the impact of different supervisory strategies has been less studied. Conducted on an internal medicine teaching service, this randomized controlled trial examined the effect of two supervisory strategies on patient safety and the educational experience for housestaff. Increased direct supervision (faculty physician physically present for duration of morning rounds, including patient care discussions and encounters with newly admitted and existing patients) was compared to standard supervision (faculty directly supervised residents only for new admissions, meeting later in the day to discuss existing patients). The study used a rigorous, previously developed methodology to track adverse event rates and found no significant difference in safety outcomes between the two groups. Residents perceived that greater supervision led to decreased autonomy in decision-making. Although the study evaluated only direct, in-person supervision, its findings demonstrate that—like reducing duty hours—increasing direct supervision of trainees does not necessarily translate to improving patient safety. The relationship between clinical supervision, education, and patient safety is discussed in a PSNet perspective.
Lyons I, Furniss D, Blandford A, et al. BMJ Qual Saf. 2018;27:892-901.
Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.
Wakeman D, Langham MR. Semin Pediatr Surg. 2018;27:107-113.
Crew resource management is a strategy from aviation that has been applied in medicine to enhance teamwork. This review discusses crew resource management as a way to improve communication, establish a safety culture, and reduce morbidity and mortality in the operating room.
Armstrong N, Brewster L, Tarrant C, et al. Soc Sci Med. 2018;198:157-164.
Measuring patient safety is critical to improvement. This ethnographic study examined the implementation of a patient safety measurement program in the United Kingdom, the NHS Safety Thermometer, which measured incidence of pressure ulcers, harm from falls, catheter-associated urinary tract infection, and venous thromboembolism, with the goal of informing local improvement efforts. Investigators sought to examine how the measurement program was perceived by frontline staff. Despite the explicit emphasis on using the data for improvement, it was viewed as an external reporting requirement. The program was also viewed as a basis to compare organizations, especially because it included pay-for-performance incentives. The authors suggest that the intention of the program did not match the real-world considerations of participating health care systems and had the unintended consequence of creating potential for blame.
Mongkhon P, Ashcroft DM, Scholfield N, et al. BMJ Qual Saf. 2018;27:902-914.
This meta-analysis sought to identify the prevalence of hospital admissions attributed to nonadherence to medications. There was significant heterogeneity among the included studies. Researchers found that about 1% to 10% of hospital admissions are due to nonadherence to medications in the outpatient setting and are therefore preventable.
Eriksson J, Gellerstedt L, Hillerås P, et al. J Clin Nurs. 2018;27(5-6):e1061-e1067.
Overcrowding in the emergency department can compromise patient safety. This qualitative study across five emergency departments found that nurses perceive prolonged stays in the emergency department to adversely affect both patient safety and their ability to provide high-quality care.
Ladapo JA, Larochelle MR, Chen A, et al. JAMA Psychiatry. 2018;75:623-630.
Patients prescribed opioids and benzodiazepines concurrently may be at increased risk for adverse drug events. Researchers used data from both the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to identify adults already using a benzodiazepine who were newly prescribed opioid medication between 2005 and 2015. Rates of opioid prescribing among patients using a benzodiazepine remained higher than rates in the general population during the entire study period.
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Implement Sci. 2018;13:50.
Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Edwards MT. Am J Med Qual. 2018;33(5):502-508.
Just culture is a movement to shift from blame for errors and instead focus on system issues in order to enhance event reporting and learning from failures. This study examined a survey about just culture in conjunction with Hospital Compare quality ratings and AHRQ's Hospital Survey on Patient Safety Culture. The vast majority of the 270 hospitals that responded to the survey reported adopting just culture. However, respondents reported no improvement in nonpunitive response to error, indicating that a culture of blame persists. The study also found no association between hospital quality ratings and just culture implementation. The author concludes that just culture is not sufficient to create a blame-free culture in hospitals. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Freund Y, Goulet H, Leblanc J, et al. JAMA Intern Med. 2018;178:812-819.
In emergency departments (EDs), high medical acuity, incomplete information, and productivity pressures can contribute to preventable adverse events and near misses. Systems solutions have improved medication safety and team communication in EDs, but few interventions have meaningfully affected diagnostic and treatment errors. Investigators conducted a randomized controlled trial to evaluate the impact of ED physicians' cross-checking their diagnostic and treatment plans with another physician. Compared with standard care, patients whose physicians performed cross-checking were 40% less likely to experience a preventable adverse event or near miss. This study's design, large sample size, and ascertainment of patient-centered outcomes were particularly robust. A past WebM&M commentary and PSNet perspective examined other initiatives to improve emergency department safety.
Patterson ES. Hum Factors. 2018;60(3):281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25(4):385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
MacLean CH, Kerr EA, Qaseem A. N Engl J Med. 2018;378:1757-1761.
Measurement of quality and patient safety is challenging. In this commentary, the authors applied a five-domain criteria to rate the validity across 86 measures used to track ambulatory internal medicine performance and determined only 32 to be valid. They advocate for revising measurement to address performance gaps.
Vaughn VM, Linder JA. BMJ Qual Saf. 2018;27:583-586.
Despite the benefits of health information technology, such systems can have detrimental effects on clinician decision-making. This commentary discusses how electronic health record design can contribute to inappropriate test ordering. The author recommends that influences such as heuristics and social norms be considered when developing electronic health record systems to improve care.
Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. Worldviews Evid Based Nurs. 2018;15:16-25.
Although the practice of evidence-based medicine is an important strategy for improving the safety and quality of health care, consistent use of known best practices does not occur. In this study, researchers sought to assess nurse competency throughout the United States across 13 evidence-based practice competencies for nurses as well as 11 additional competencies for advanced practice nurses. They administered an anonymous online survey and received responses from 2344 nurses across 19 hospitals or health systems. In general, nurses reported a lack of competency across all 24 domains, but younger nurses and those with more training reported better competency. A recent PSNet interview discussed the role of nurses with regard to patient safety and outcomes.
Kim BY, Sharafoddini A, Tran N, et al. JMIR Mhealth Uhealth. 2018;6:e74.
Patients are powerful allies in improving medication safety. This study found that available mobile applications that enable patients to check for drug–drug interactions are of moderate quality and low cost. They did not assess efficacy. An Annual Perspective examined other technological innovations for engaging patients in safety.
Yeung S, Downing L, Fei-Fei L, et al. New Engl J Med. 2018;378(14):1271-1273.
Artificial intelligence technologies can support diagnostic decision-making. This commentary discusses application of deep learning tools to create visual cues to track deviations in activities to flag areas of improvement. Although early in its development, the authors outline the potential of this technology in clinical care and review early efforts employed to enhance hand hygiene.
Haas S, Gawande A, Reynolds ME. JAMA. 2018;319:1765-1766.
Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.