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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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Parshuram CS, Dryden-Palmer K, Farrell C, et al. JAMA. 2018;319(10):1002-1012.
Identifying incipient clinical deterioration is a prerequisite for rapid response and prevention of harm for hospitalized patients. This study tested a bedside pediatric early warning system, which included an illness severity score, standardized documentation, and monitoring protocols. In a cluster-randomized trial in several high-income countries, implementation of the bundle did not result in decreased in-hospital mortality compared to usual care. The overall mortality rate in the study was less than 0.2%. The authors suggest that this unexpectedly low mortality rate may have made it difficult to detect differences in intervention versus control hospitals. A related editorial suggests that artificial intelligence should be used to identify clinical deterioration and that outcomes beyond mortality should be considered in their evaluation.
Darnall BD, Ziadni MS, Stieg RL, et al. JAMA Intern Med. 2018;178:707-708.
This prospective cohort study found that many outpatients treated at a chronic pain clinic were willing to voluntarily taper opioid medications. Although nearly 40% of patients dropped out of the study, those that remained significantly reduced their opioid dosing. The authors suggest that offering a voluntary gradual opioid taper to patients with chronic pain may reduce their opioid dose.
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
This collection of articles and case studies covers how health care organizations are working to establish and sustain a safety culture. The material includes discussions on the role of leadership, professionalism, and high reliability in improving work environments to support safety.
Wong A, Amato MG, Seger DL, et al. BMJ Qual Saf. 2018;27:718-724.
Clinical decision support systems in electronic health records (EHRs) aim to avert adverse events, especially medication errors. However, alerts are pervasive and often irrelevant, leading patient safety experts to question whether their modest improvement in safety outweighs the harms of alert fatigue. This study assessed provider overrides of a commercial EHR's medication alerts in intensive care units at one institution. Providers overrode most alerts, and the majority of those overrides were appropriate. Inappropriate overrides occasionally led to medication errors and did so more frequently than appropriate overrides. A recent WebM&M commentary recommends employing human factors engineering to make clinical decision support more effective.
Axeen S, Seabury SA, Menchine M. Ann Emerg Med. 2018;71(6):659-667.e3.
As deaths and overdoses related to opioid use have increased, physician prescribing behavior is under greater scrutiny. Prior research has shown significant variation in opioid prescribing among emergency medicine physicians, but the degree to which emergency department prescribing contributes to overall opioid prescribing remains unknown. This retrospective study used data from the Medical Expenditure Panel Survey from 1996 to 2012 and found that the quantity of opioids prescribed increased by 471% during the study period. While the percentage of opioids prescribed in the ambulatory setting increased from 71% in 1996 to 83% in 2012, the percentage of opioids prescribed in the emergency department decreased from 7.4% in 1996 to 4.4% in 2012. Based on these findings, the authors suggest that interventions designed to reduce opioid prescribing should target the outpatient setting rather than the emergency department. A past PSNet perspective discussed opioid medications and associated patient safety risks.
Liberman AL, Newman-Toker DE. BMJ Qual Saf. 2018;27(7):557-566.
Patient safety measurement remains challenging. This article describes a framework to address gaps in measuring diagnostic error. The authors propose utilizing big data to develop diagnostic performance dashboards and benchmarking tools that support proactive learning and improvement strategies.
Lin CA, Shah K, Mauntel LCC, et al. Am J Health Syst Pharm. 2018;75:153-158.
Errors in medication delivery can result in patient harm. This commentary introduces use of drones as a way to improve patient access to medications. The authors outline regulatory and safety factors that stakeholders seeking to utilize drone technology should consider.
Olson APJ, Graber ML, Singh H. J Gen Intern Med. 2018;33:1187-1191.
Research is increasingly focusing on diagnostic errors and strategies to reduce them. The challenges of measuring diagnostic difficulties has hindered progress. This commentary outlines a conceptual approach to identifying "undesirable diagnostic events." The authors propose developing a list of clinical contexts and specific diseases prone to diagnostic error. Candidate conditions should be diagnosable in routine practice with a clear reference standard and defined diagnostic process. They also contend that measures should be constructed for relatively common conditions that are often misdiagnosed and for which delayed diagnosis could lead to harm, such as delayed cancer diagnosis. The authors propose designing and testing diagnosis measures based on this framework. A previous PSNet perspective by the senior author, Hardeep Singh, discussed momentum in the field of diagnostic error over the past several years.
Phillips JM, Stalter AM, Winegardner S, et al. Nurs Forum. 2018;2018(3):286-298.
Unprofessional behavior among clinicians adversely affects patient safety and the quality of care. This literature review sought to apply a systems approach to studies of workplace civility in nursing. The included studies demonstrated that rude behavior is perceived to diminish care quality, increase risk of adverse events, and worsen patient satisfaction. Researchers identified triggers for workplace incivility, such as negative organizational climate and power imbalances, as well as consequences including low self-esteem and decreased productivity. The authors note that high stress environments can foster incivility and lead to burnout. They recommend practice-based competency in civility in order to improve patient safety. A previous PSNet perspective discussed how to identify and manage problem behaviors.
Brinkman DJ, Tichelaar J, Graaf S, et al. Br J Clin Pharmacol. 2018;84(4):615-635.
This literature review examined whether graduating medical students have achieved competence in safe medication prescribing. The included studies showed a lack of consensus about the standards for safe prescribing education in medical school and variation in prescribing skills and knowledge. The authors call for larger and more rigorous studies and clear educational standards to promote safer medication prescribing.
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. JAMA Intern Med. 2018;178:375-382.
Preventable harm is common during and after hospital discharge. Pharmacist-delivered medication reconciliation has been proposed as a strategy to reduce adverse medication events and readmissions. Investigators conducted a three-arm randomized controlled trial comparing the effect of pharmacist-delivered medication reviews, motivational interviews, and postdischarge follow-up with nursing homes, primary care providers, and pharmacies (extended intervention); simple inpatient medication reconciliation (basic intervention); and usual care (no intervention) on outcomes for medically complex patients. The extended intervention reduced hospital readmissions and emergency department visits within 180 days of discharge while the basic intervention did not. This trial was large, robustly conducted, and demonstrated a durable improvement in safety for patients at increased readmission risk. A previous Annual Perspective explored tools for safer transitions of care.
Ofoma UR, Basnet S, Berger A, et al. J Am Coll Cardiol. 2018;71:402-411.
The weekend effect has been observed for many conditions. A patient who has an in-hospital cardiac arrest at night or during the weekend is less likely to be successfully resuscitated or survive hospitalization than a patient whose heart stops in the hospital on a weekday. In this large retrospective cohort study, researchers examined trends in in-hospital cardiac arrests over 15 years. Resuscitation and survival to hospital discharge improved nearly 75% overall. The weekend effect persisted, especially in survival to hospital discharge. An accompanying editorial hypothesizes that during nights and weekends fewer specialists are available and fatigue may impair providers' psychomotor skills. A previous PSNet interview highlighted techniques for achieving high reliability at all times of day.
Dzau VJ, Kirch DG, Nasca TJ. New England Journal of Medicine. 2018;378.
Physician burnout remains a critical threat to physician well-being and patient safety. Prodigious documentation requirements, escalating productivity demands, and deleterious organizational culture all contribute to physicians burning out at twice the rate of other professionals. In this commentary, leaders of the National Academy of Medicine, Association of American Medical Colleges, and Accreditation Council for Graduate Medical Education describe their crosscutting collaborative to understand burnout, teach about its dangers, and foster meaningful solutions. A related editorial highlights successful burnout initiatives such as standardized assessments and team-based models of primary care to reduce physicians' clerical burden. An Annual Perspective explored the relationship between burnout and patient safety and reviewed strategies to address burnout among clinicians.
Liberati EG, Peerally MF, Dixon-Woods M. Int J Qual Health Care. 2018;30:39-43.
The field of patient safety has long looked to high reliability organizations like aviation or nuclear power for solutions, but it is unclear how well such approaches translate to health care settings. In this study, researchers asked clinicians to identify safety hazards from their own work and then propose solutions. After applying a systems thinking framework to clinicians' solution ideas, they found that most of the clinician-generated safety approaches would be considered ineffective by high reliability standards. The authors suggest that industrial frameworks are an imperfect match for health care settings and should be used with caution. A recent PSNet interview with the study's senior author, Mary Dixon-Woods, discusses the sociology of health care versus other industries.
Brat GA, Agniel D, Beam A, et al. BMJ. 2018;360:j5790.
Harm from opioids is a widely recognized patient safety concern. In this retrospective cohort study, investigators examined the effect of postoperative opioid prescribing in patients who had never received opioids before. As with prior studies, they found increased subsequent misuse of opioids among patients who received larger quantities of opioid medications following surgery compared to those who received fewer opioid medications. Longer duration of postoperative opioid prescription was also associated with higher odds of future diagnosis of opioid misuse. This study adds to evidence demonstrating the potential harms associated with even short-term opioid prescription. A recent PSNet interview discussed the opioid epidemic and strategies to address this growing patient safety concern.
Parent B, LaGrone LN, Albirair MT, et al. JAMA Surg. 2018;153:464-470.
Handoffs represent a significant risk to patient safety. Standardizing communication during the handoff process has the potential to reduce harm. In this trial, researchers assessed the impact of a standardized handoff curriculum on perceived interprovider communication in eight intensive care units (ICUs) across two hospital systems. Although the curriculum was perceived to improve shift preparedness among providers, they found no association with better patient outcomes in the ICUs, including length of stay, duration of mechanical ventilation, or reintubations. An accompanying editorial suggests that further research on standardized handoffs in the ICU is necessary to better understand the potential for improving patient outcomes. A previous PSNet interview discussed handoffs and the implementation and findings of the landmark I-PASS study.
Bhise V, Meyer AND, Menon S, et al. Int J Qual Health Care. 2018;30(1):2-8.
Reducing diagnostic error is an area of increasing focus within patient safety. However, little is known about how patients perceive physician communication regarding diagnostic uncertainty. In this study, participants (parents of pediatric patients) were assigned to read one of three clinical vignettes each describing a different approach to a physician communicating diagnostic uncertainty; they were then asked to answer a questionnaire. Researchers found that explicit expression of diagnostic uncertainty by a physician was associated with negative perceptions of physician competence as well as diminished trust and satisfaction with care, whereas more implicit language was not. A past Annual Perspective highlighted some of the challenges associated with diagnostic error.
Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319(2):143-153.
Handoffs between providers are inevitable and are known to introduce risks. This retrospective population-based cohort study in Canada examined the effects of intraoperative handoffs between anesthesiologists on major complications, readmissions, and 30-day mortality among patients undergoing surgery. After adjustment for patient and site characteristics, patients who experienced an anesthesiologist handoff had higher rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. The number of surgeries in which a handoff occurred increased over time during the 6-year study period. These results suggest that limiting intraoperative anesthesiologist handoffs may improve safety. However, a related editorial posits that reducing handoffs is a simplistic solution that may have unintended consequences and instead recommends that quality improvement approaches, such as developing standardized handoff procedures, may result in more meaningful enhancements for intraoperative anesthesia safety.
Philadelphia, PA: Pew Charitable Trusts; December 2017.
The usability of health information technologies (IT) is a key component to their safe effective use. This report introduces problems that surface due to poor design of health IT systems, summarizes expert opinion on the role of system usability in patient safety, and describes an approach to monitor and improve the safety of health IT by engaging multistakeholder collaboration.
Campione J, Famolaro T. Jt Comm J Qual Patient Saf. 2018;44:23-32.
Measuring hospital safety culture is considered a best practice supported by both the Agency for Healthcare Research and Quality (AHRQ) and the Leapfrog Group. Although the data linking positive safety culture to patient outcomes is inconclusive, establishing a strong culture of safety is considered essential to patient safety. Researchers analyzed AHRQ Survey on Patient Safety Culture data submitted by 536 hospitals from 2007 through 2014 and identified 6 large (> 400 beds) hospitals demonstrating significant improvement over time. They then conducted interviews with quality leaders from those institutions. Qualitative analysis of interview transcripts revealed common best practices across those hospitals, including systematic safety culture measurement, widespread communication of results, both leadership and frontline engagement in improvement efforts, and implementation of patient safety initiatives. A PSNet perspective discussed how to improve safety culture.