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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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Bejnordi BE, Veta M, van Diest PJ, et al. JAMA. 2017;318:2199-2210.
Diagnostic error is a growing area of focus within patient safety. Artificial intelligence has the potential to improve the diagnostic process, both in terms of accuracy and efficiency. In this study, investigators compared the use of automated deep learning algorithms for detecting metastatic disease in stained tissue sections of lymph nodes of women with breast cancer to pathologists' diagnoses. The algorithms were developed by researchers as part of a competition and their performance was assessed on a test set of 129 slides, 49 with metastatic disease and 80 without. A panel of 11 pathologists evaluated the same slides with a 2-hour time limit and one pathologist evaluated the slides without any time constraints. The authors conclude that some of the algorithms demonstrated better diagnostic performance than the pathologists did, but they suggest that further testing in a clinical setting is warranted. An accompanying editorial discusses the potential of artificial intelligence in health care.
Harbaugh CM, Lee JS, Hu HM, et al. Pediatrics. 2018;141(1):e20172439.
Opioid misuse is an urgent patient safety issue. Research has found that a significant proportion of adults prescribed opioids in the short term remain on opioid medications chronically, but less is known about postsurgical opioid use among pediatric patients. This study analyzed a large, commercial health care claims database to determine whether children and adolescents prescribed opioids following surgery were more likely to be prescribed opioids 3 to 6 months later, compared to children who did not undergo surgery. Researchers found that postoperative opioid use was associated with persistent opioid use. A related editorial raises questions about the breadth of procedures included and calls for development and implementation of evidence-based pediatric pain management strategies that address the risk for persistent opioid use and misuse.
Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
Aldridge C, Bion J, Boyal A, et al. Lancet. 2016;388:178-86.
In-hospital mortality for many conditions is higher on the weekends than on weekdays—a phenomenon known as the weekend effect. Some hypothesize lower specialty physician staffing levels on weekends explains the mortality difference. This cross-sectional study compared specialist staffing levels and mortality rates at 115 hospitals in the English National Health Service on Sundays compared to Wednesdays. Researchers found a higher mortality rate and lower intensity of specialty services on weekends, but there was no correlation between the two ratios. Although this study is not definitive, it does imply that alternate mechanisms may explain the weekend effect, such as case mix differences, variation in nonphysician staffing, or lower availability of diagnostic services. A previous PSNet interview discussed the weekend effect in health care.
Gupta A, Allen LA, Bhatt DL, et al. JAMA Cardiol. 2018;3:44-53.
Readmissions are a focus of patient safety efforts, especially in light of Medicare's nonpayment policy. This retrospective, interrupted time-series analysis examined whether reduction in readmissions for heart failure led to any change in health outcomes. This study analyzed data from a national clinical registry of patients with heart failure admitted between 2006 and 2014, spanning the implementation of Medicare nonpayment. Similar to prior studies, there was a decline in readmission rates observed after implementation of penalties. In this cohort, researchers also observed increases in 30-day and 1-year risk-adjusted mortality. The authors conclude that penalties for readmissions may have unintended negative consequences for patient outcomes. A previous PSNet interview discussed the benefits and limitations of Medicare's nonpayment policy.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton : CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Sexton B, Adair KC, Leonard MW, et al. BMJ Qual Saf. 2018;27(4):261-270.
Achieving an optimal culture of safety is a central component of patient safety. Prior research supports that higher levels of employee engagement are correlated with improved perceptions of safety culture and that higher rates of burnout are associated with more negative perceptions of safety culture. Leadership WalkRounds has been touted as an intervention to improve safety culture, although the evidence for its efficacy has been mixed. In a more recent study, clinical units that received feedback from walkrounds had lower rates of burnout and more positive perceptions of safety culture. In this cross-sectional survey study, researchers analyzed the relationship between receiving feedback on the actions resulting from walkrounds and health care employees' perceptions of safety culture, engagement, burnout, and work–life balance across 829 settings. Work environments in which walkrounds were conducted with feedback had higher safety culture and employee engagement scores. A past PSNet interview and Annual Perspective discussed the relationship between burnout and patient safety.
Bhise V, Rajan SS, Sittig DF, et al. J Gen Intern Med. 2018;33(1):103-115.
Recognizing and measuring diagnostic error can be challenging, which hinders efforts to study and improve diagnosis. This systematic review of 123 studies sought to characterize diagnostic uncertainty. Despite the lack of an explicit definition in any study, researchers identified diagnostic uncertainty as a clinician perception that affects diagnostic evaluation and changes over time. Strategies to measure diagnostic uncertainty included assessing clinician perceptions through survey or interview methods, examining the diagnostic evaluation through medical record review, or employing simulation with standardized cases or vignettes. The authors propose the following definition of diagnostic uncertainty: "subjective perception of an inability to provide an accurate explanation of the patient's health problem," paralleling the National Academy of Medicine's definition of diagnosis. A recent WebM&M commentary discussed how cognition influences diagnostic decision-making.
Chicago, IL: NORC at the University of Chicago and IHI/NPSF Lucian Leape Institute; 2017.
Patient perspectives have been shown to identify otherwise undetected adverse events. This Institute for Healthcare Improvement–National Patient Safety Foundation commissioned survey, an update to their original 1997 survey, interviewed a probability-based sample of 2536 American adults. The results demonstrate the widespread nature of patient safety problems. Overall, 20% of respondents reported personally experiencing a medical error, most often in the outpatient setting. However, only 10% of respondents said they experienced harm when receiving medical care, which underscores the contrast between error and harm. The most common type of error was a missed or delayed diagnosis, followed by a communication error. About a third of errors were not reported. These results highlight the need to focus on diagnostic safety in the outpatient setting in order to improve patient safety in United States health care.
Thiels CA, Anderson SS, Ubl DS, et al. Ann Surg. 2017;266:564-573.
Opioid-related mortality is a patient safety concern. Prior studies have demonstrated that postdischarge opioid prescribing can lead to chronic use in opioid-naïve patients. This retrospective observational study examined the amount and duration of opioid prescribing following 25 common elective surgical procedures. Nearly all patients were prescribed opioids after elective surgery. The median amount of opioids prescribed, 375 oral morphine equivalents, was nearly twice the maximum recommended. Quantity of opioids prescribed differed by sex, body weight, age, and diagnosis, and there were also significant variations among the three institutions included in the study. The authors call for standardizing and optimizing postsurgical opioid prescribing.
Bhise V, Sittig DF, Vaghani V, et al. BMJ Qual Saf. 2018;27:241-246.
Identifying adverse events in real time remains a patient safety challenge. Trigger tools—structured data values such as abnormal test results or administration of a specific medication reversal agent—can detect a potential adverse event. Investigators sought to refine the Institute of Healthcare Improvement Global Trigger Tool to more efficiently and accurately identify preventable adverse events among hospitalized patients. They surmised that care escalation would be more likely to be due to a preventable patient safety problem than underlying illness among younger patients with fewer comorbid conditions. Among these patients, they applied a modified trigger tool to identify cases of possible adverse events. Two physicians then reviewed the records for triggered cases to determine whether a preventable adverse event occurred, as in prior studies. About half of trigger-positive cases represented preventable adverse events, and there was moderate agreement between the two reviewers. The authors conclude that this modified trigger tool and record review procedure advances the methodology of adverse event identification in hospitalized patients.
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266(4):582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Rhee C, Dantes R, Epstein L, et al. JAMA. 2017;318(13):1241-1249.
Early identification of sepsis is essential for initiating appropriate treatment and preventing mortality. In this retrospective study, researchers used clinical data to estimate the incidence of sepsis over time at 409 academic, community, and federal hospitals over a 6-year period. They found that the incidence of sepsis remained stable during this time. Although inpatient mortality due to sepsis declined somewhat, there was no change in the combined outcome of death or discharge to hospice. In contrast, analysis of claims-based data suggests a significant increase in the incidence of sepsis over time as well as a marked decrease in sepsis mortality and death or discharge to hospice. The authors conclude that analysis of clinical data may provide a better understanding of sepsis trends. The accompanying editorial highlights challenges associated with measuring the sepsis incidence and mortality.
Washington, DC: National Quality Forum. September 19, 2017.
Although diagnostic error is a well-recognized source of preventable patient harm, measuring and mitigating diagnostic error remains challenging. This National Quality Forum report describes the development of a framework to assist with measuring diagnostic quality and safety. The framework outlines 3 domains and 11 subdomains for measuring diagnostic quality and safety as well as 62 prioritized measure concepts. High-priority areas for measure development include timeliness of diagnosis, timely follow-up of test results, communication and handoffs, patient-reported diagnostic errors, and patient experience related to diagnostic care. The committee also identified several cross-cutting themes and makes recommendations for researchers seeking to develop measures to improve diagnostic safety. A PSNet perspective discussed challenges and opportunities regarding diagnostic error.
Krumholz HM, Wang K, Lin Z, et al. N Engl J Med. 2017;377:1055-1064.
Avoiding readmissions has been an important safety goal, especially since Medicare has implemented nonpayment policies. Patient factors like health literacy and access to outpatient follow-up care have been implicated in previous research on readmissions. In contrast, this study sought to determine whether hospital quality affects readmission rates. By examining patients with multiple admissions for the same diagnosis but at different hospitals, they were able to focus on the effect of the hospital alone. Hospitals were divided into four tiers based on their known overall rate of readmissions, and then investigators assessed whether a given patient was more or less likely to be readmitted based on these tiers. They found a higher likelihood of a given patient being readmitted at hospitals in the tier with the most readmissions compared to those hospitals in the lowest readmission tier. The authors conclude that hospital readmissions are in part due to hospital factors as well as individual factors. This finding suggests that targeting hospital safety practices could reduce readmissions.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Battles J; Azam I; Grady M; Reback K; Agency for Healthcare Research and Quality; AHRQ.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Lyren A, Brilli RJ, Zieker K, et al. Pediatrics. 2017;140.
Improving patient safety often involves multifaceted interventions intended to change complex workflows. This prospective cohort study examined whether a collaborative improvement initiative across 33 pediatric hospitals could augment patient safety. Hospitals volunteered to be part of the collaborative and paid an annual fee to participate. All but one submitted their safety data for inclusion in the study. The intervention involved identification and dissemination of evidence-based practices to reduce hospital-acquired conditions and prevent serious adverse events. Each hospital implemented these best practices locally according to their preferences. The collaborative provided virtual and in-person training for patient safety processes, such as unit-based safety rounds, root cause analysis, and inclusion of patients and families on hospital committees. Rates of hospital-acquired conditions and serious adverse events declined over time during the 3-year study. Because there were no concurrent control hospitals, it is not clear whether these improvements can be attributed to the intervention. The authors conclude that participation in a learning collaborative can enhance patient safety.
Dekker S. Boca Baton, FL: CRC Press; 2017.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27(1):53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.