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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.

 

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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Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33(7):1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
Amjad H, Roth DL, Sheehan OC, et al. J Gen Intern Med. 2018;33:1131-1138.
This observation study found that patients who met criteria for dementia using objective assessments often lacked a formal dementia diagnosis, even when they regularly received medical care. Many patients who were diagnosed with dementia were not aware of their diagnosis. These results indicate the need to improve both diagnosis of dementia and communication regarding dementia diagnosis.
Gupta N, Vujicic M, Blatz A. J Am Dent Assoc. 2018;149:237-245.e6.
This analysis of claims data from insurers found that rates of opioid prescribing following dental procedures increased between 2010 and 2015. The sharpest rise occurred among 11–18 year olds, and nearly one-third of opioid prescriptions were not associated with surgical procedures. The authors urge limiting use of opioids for nonsurgical dental visits.
Weingart SN, Zhang L, Sweeney M, et al. Lancet Oncol. 2018;19:e191-e199.
Chemotherapy errors can result in serious patient harm. This review summarized the evidence on chemotherapy errors. Most studies were performed in single-institution academic settings and few studies examined how health information technology affects patient outcomes.
Lee TT, Kesselheim AS. Ann Intern Med. 2018;168:730-732.
Innovation is a valuable process in health care. However, when innovations are rapidly deployed, efforts to proactively identify and address safety concerns may fall short and lead to unintended consequences. This commentary describes a new program to expedite the review of digital health software and summarizes the benefits and potential harms that could result from the program.
Thomas LR, Ripp JA, West CP. JAMA. 2018;319:1541-1542.
Clinician burnout is a growing concern with known patient safety implications. This commentary describes a charter for health care organizations to prioritize physician well-being in order to preserve quality and safety of patient care. The charter includes elements known to contribute to safety, such as a positive work culture and leadership engagement. The authors call for reducing time spent on documentation and administration, consistent with prior studies. A related editorial emphasizes the importance of the physician–patient relationship in creating meaning and joy in physician work. A previous PSNet interview and perspective discussed the relationship between physician professional satisfaction and patient safety.
Thorpe KE, Joski P, Johnston KJ. Health Aff (Millwood). 2018;37(4):662-669.
Infections with antibiotic-resistant organisms are increasingly common in hospitals and ambulatory care, primarily driven by overuse of antibiotics for treatment of nonbacterial illnesses. This economic analysis found that antibiotic-resistant infections have doubled in incidence since 2002, and they add approximately $1,400 to the cost of care for each patient with an antibiotic-resistant infection. The study was performed using data from the Medical Expenditure Panel Survey, which is conducted by AHRQ. This survey does not include data on institutionalized adults, such as residents of long-term care facilities. Since antibiotic-resistant infections are common in these patients, this study may actually underestimate the total economic burden of these infections. The devastating effects of an antibiotic-resistant infection for a health care practitioner were vividly illustrated in a PSNet perspective.
Howe JL, Adams KT, Hettinger Z, et al. JAMA. 2018;319(12):1276-1278.
As electronic health records (EHRs) have become ubiquitous, our understanding of their benefits and potential harms has evolved. In particular, issues with EHR usability (the ease of understanding, learning, and using the interface) impair physician workflow and may result in harm to patients. In this study, investigators analyzed voluntary error reports from the Pennsylvania Patient Safety Authority and a multihospital academic health system for evidence of safety issues related to EHR usability. Although limited by the nature of the voluntary reports, which contained sparse details precluding assessment of causal factors, investigators did identify and categorize cases in which problems with EHR usability may have directly resulted in patient harm. Many EHR contracts with health care organizations include "hold harmless" clauses limiting the EHR vendors' legal liability, meaning that patients may not be able to seek compensation if EHR issues directly lead to harm. A WebM&M commentary discussed a case of contrast nephropathy arising in part due to a confusing EHR user interface.
O'Hara JK, Reynolds C, Moore S, et al. BMJ Qual Saf. 2018;27:673-682.
Patients' reports of safety concerns can reveal adverse events that would not be identified otherwise. In this cluster-randomized trial of patient engagement, patient volunteers read and classified incident reports submitted by hospitalized patients enrolled in the study. Following classification by patients, reports underwent a standardized, validated review by multiple researchers to determine if the event constituted a patient safety incident. Overall, about one-third of patient-reported concerns were deemed to be patient safety incidents. Medication safety issues were the most prevalent concerns. The authors conclude that patient reporting of safety events lends a unique and necessary perspective to error reporting. A previous PSNet perspective highlighted the advantages to and limitations of engaging patients in patient safety.
Kane JM, Colvin JD, Bartlett AH, et al. Pediatrics. 2018;141(4):e20173335.
Opioid-related harm is a widely recognized patient safety concern. This study retrospectively examined critical care unit hospitalizations for opioid ingestions among children between 2004 and 2015. Over this period, hospitalizations for opioid ingestion increased dramatically, and nearly half led to critical care unit admission. Although the mortality rate for pediatric opioid ingestion was 1.6%, more than one-third of cases required mechanical ventilation. The authors call for stronger efforts to address the impact of the opioid epidemic on children. A previous PSNet interview discussed factors that contributed to the increase in opioid-related harm and strategies to address this growing patient safety concern.
Walker E, McMahan R, Barnes D, et al. J Pain Symptom Manage. 2018;55:256-264.
This study found that electronic health record documentation of patients' preferences for advance care planning was incomplete. Only half of participants had documented preferences available, and the documentation was often difficult to locate and interpret. The authors conclude that electronic health records should be designed to better capture patients' preferences.
Desai SV, Asch DA, Bellini LM, et al. New England Journal of Medicine. 2018;378.
Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.
Shah T, Patel-Teague S, Kroupa L, et al. BMJ Qual Saf. 2018;28.
Alert fatigue associated with electronic health records (EHRs) contributes to primary care physician burnout and can increase medication errors. The phenomenon is especially well-described in the Veterans Affairs (VA) system, where providers receive more than 100 alerts per day, which require an average of 85 seconds to address. This study describes a nationwide VA initiative to reduce EHR alerts in primary care and teach providers to process alerts more efficiently. Alerts decreased by a small but significant amount—from an average of 128 per day to an average of 116 per day. Providers who received the most alerts before the initiative experienced the largest alert reduction. A PSNet perspective described a way forward in improving EHR safety.
Ho A, Quick O. BMC Med Ethics. 2018;19:18.
Although use of smart technologies for self-diagnosis and care management offers patients convenience, cost-savings, and expediency, they may also contribute to poor decision-making and harm. This commentary explores the impact of direct-to-consumer monitoring devices and smartphone applications on care and the therapeutic relationship. The authors advocate for regulation and assessment regarding accuracy of these tools.
Yorkgitis BK, Brat GA. Am J Surg. 2018;215:707-711.
Use of mnemonics to recall standardized steps can help augment reliability. This review discusses the development of the RIGHTT mnemonic (Risk for adverse event, Insight into pain, Going over pain plan, Halting opioids, Tossing unused opioids and Trouble identification) designed to help surgeons improve safety of opioid prescribing for surgical pain.
Martin GP, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27(9):710-717.
A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Nix M, McNamara P, Genevro J, et al. Health Aff (Millwood). 2018;37:205-212.
Learning collaboratives are multimodal interventions that are often used to implement evidence-based practices. This perspective from AHRQ scientists proposes a taxonomy to describe collaboratives' distinct elements: innovation, or the type of positive change; communication among members; duration and sustainability; and social systems, or the organization and culture of the collaborative. The authors suggest that efforts to evaluate learning collaboratives or quality improvement interventions employ this taxonomy.
Chang B, Kaye AD, Diaz JH, et al. J Patient Saf. 2018;14:9-16.
This retrospective study of the National Anesthesia Clinical Outcomes Registry database determined that complications were more common for procedures performed in the operating room compared to procedures performed outside the operating room. This finding may be due to adverse selection, in which patients at higher risk for complications are intentionally treated in the operating room environment. A past WebM&M commentary discussed an adverse event related to a procedure at an outpatient center.
Tolley CL, Slight SP, Husband AK, et al. Am J Health Syst Pharm. 2018;75(4):239-246.
This systematic review of clinical decision support for safe medication use found that such systems are incompletely implemented and lack standardization and integration of patient-specific factors. The authors suggest that reducing alert fatigue and employing human factors principles would enhance decision support effectiveness.