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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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Baker R, Norton PG, Flintoft V, et al. CMAJ. 2004;170:1678-86.
Using methodology originally developed for the Harvard Medical Practice Study, the authors reviewed more than 4000 hospitalizations from 20 Canadian hospitals in order to estimate the degree of iatrogenic harm suffered by patients.  Overall, 7.5% of patients suffered at least one adverse event, of which more than one-third were felt to be preventable.  These data are similar to prior studies conducted in the United States and Australia, but (as with prior studies) reviewer agreement on the presence and preventability of errors was only moderate.
Lingard L, Espin S, Whyte S, et al. Qual Saf Health Care. 2004;13:330-4.
This study used direct observation of 48 surgical procedures to characterize deficits in communication among team members.  Problematic communication occurred in nearly one-third of all exchanges between team members, and appeared to have direct effects on patient safety through increasing tension and creating the need for workarounds.  Communication and teamwork in the operating room was the subject of a classic study of safety culture.
Chang A, Schyve PM, Croteau RJ, et al. Int J Qual Health Care. 2005;17:95-105.
The rapid increase in research and publications on patient safety following the landmark Institute of Medicine report resulted in the need for a common set of definitions and terminology for patient safety concepts.  To achieve this goal, the authors developed a taxonomy based on a systematic literature review.  The taxonomy, which has been widely accepted since its publication, consists of 5 primary classifications that can be used to classify an error:  impact, type, domain, cause, and prevention or mitigation.
Altman DE, Clancy CM, Blendon RJ. New England Journal of Medicine. 2004;351.
This commentary offers a perspective on the progress made since release of the IOM report in 1999. The authors discuss the growing number of stakeholders involved in safety and the need for both public and private sectors in shaping the next 5 years of progress. They discuss some of the success and the tremendous work that lies ahead in framing a common vision for the future of patient safety efforts. Two similar articles reflected on this 5-year period as well, one published in Health Affairs and the other in JAMA.
Wachter RM. Health Aff. 2004;23.
This commentary discusses the progress made since the IOM report by reviewing the context to the patient safety movement, how health care became so unsafe, and what broad categories have played a role in shaping the current patient safety milieu. The author, who also wrote Internal Bleeding, provides a grade for the broad categories impacting safety efforts, which include regulation, error-reporting systems, information technology, the malpractice system, and workforce and training issues. Two similar articles reflected on this 5-year period, one published in the New England Journal of Medicine and the other in the Journal of the American Medical Association.
Walshe K, Shortell SM. Health Aff (Millwood). 2004;23:103-11.
The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the Bristol Royal Infirmary cardiac surgery scandal—to determine the nature of the system factors that resulted in patient harm.  In most cases, problems were well known, but not addressed, indicating pervasive problems with safety culture and barriers to reporting and investigation of such incidents.  The authors call for improvements in reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures.  
Pronovost PJ, Thompson DA, Holzmueller CG, et al. Crit Care Clin. 2005;21:1-19, vii.
This review discusses the increasing demand for improving patient safety by presenting a framework for investigation. The authors begin with an overview of safety terms and the basics of safety and quality measurement while also sharing the challenges in choosing process versus outcome measures and tracking compliance with evidence-based guidelines. A number of case examples are provided to illustrate the various issues facing safety and quality researchers trying to apply the best tools. The discussion also includes the benefits and limitations of these measurement tools, including the Agency for Healthcare and Research Quality (AHRQ) Patient Safety Indicators. While the intensive care unit represents the contextual background for this review, a past study also discussed measurement strategies for patient safety more broadly.
Ash JS, Berg M, Coiera E. J Am Med Inform Assoc. 2004;11:104-12.
The authors draw from their aggregated experience in qualitative assessment of clinical information systems in the United States, Europe, and Australia to propose a framework for understanding unexpected adverse consequences of patient care information systems (PCIS) on clinical work. The adverse effects are broadly divided into errors in the process of entering and retrieving information in or from the system and errors in the communication and coordination processes that the PCIS is intended to support. The authors highlight the mismatch between the linear, rigid design of software and the cognitive, social, and organizational realities of health care delivery. The article was among the first and most influential in a wave of papers highlighting potential drawbacks in clinical information technology, and tempering the impression of computerized provider order entry systems as a universal good.
Berger RG, Kichak JP. J Am Med Inform Assoc. 2004;11:100-3.
The authors critically review the published data that traditionally support computerized physician order entry (CPOE) as means to improve patient safety and reduce costs. Through reanalysis of the work of Bates, Classen, and others, the authors challenge the accepted premise of CPOE's benefits, suggesting that CPOE is an unproven technology and that the broad policy enthusiasm for its adoption is premature.
Eccles M, Grimshaw J, Campbell M, et al. Qual Saf Health Care. 2003;12:47-52.
This review discusses the wide range of available methods to study quality improvement projects. The authors provide a framework for evaluating work of this nature and focus specifically on quantitative designs. They discuss the nuances of selecting randomized versus non-randomized approaches and the tradeoffs of each approach for evaluating a given intervention. Numerous examples are included that offer insight into the challenges of measuring effectiveness in quality improvement efforts. The authors advocate for selecting an evaluation strategy that meets the needs and available resources of a given project while minimizing bias and maximizing generalizability. The review and accompanying discussion apply directly to work in patient safety, which shares the same challenges in evaluation design.
Howard S K, Gaba D M, Smith B E, et al. Anesthesiology. 2003;98(6):1345-1355.
This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.
Rogers AE, Hwang W-T, Scott LD, et al. Health Aff (Millwood). 2004;23(4):202-212.
This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.