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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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Han B, Compton WM, Blanco C, et al. Ann Intern Med. 2017;167(5):293-301.
Opioid safety is currently the nation's most pressing public health issue, with death rates from opioid prescriptions approaching epidemic levels. In this study, the investigators used data from the 2015 National Survey on Drug Use and Health to estimate rates of opioid use and misuse in the United States population. More than one-third of adults reported using prescription opioids in the past year and nearly 5% reported misusing opioids (defined as any use not directed by a physician, including use without a prescription and use at a higher dose or for longer than prescribed). The majority of patients who misused opioids did so without a prescription, with many patients obtaining opioids from friends or relatives. Among those who misused opioids, most did so seeking relief from pain—indicating that untreated pain is common in the population and raising concern that simply reducing opioid prescribing without providing alternative pain treatment modalities could be harmful to patients. A recent PSNet perspective discussed the patient safety aspects of the opioid epidemic.
Dharmarajan K, Wang Y, Lin Z, et al. JAMA. 2017;318:270-278.
Reducing hospital readmissions is a major patient safety priority. The Centers for Medicare and Medicaid Services policy of nonpayment for readmissions for certain conditions has decreased their incidence. However, the impact of this policy on 30-day postdischarge mortality remains unknown. Researchers conducted a retrospective study of Medicare fee-for-service patients admitted to hospitals with heart failure, acute myocardial infarction, or pneumonia from 2008 through 2014. They calculated monthly 30-day risk-adjusted readmission rates and 30-day risk-adjusted mortality rates for each condition at each hospital. They then examined the association between hospitals' monthly trends in 30-day readmissions and 30-day mortality after discharge for each condition. The authors found a weak but significant association between decreased 30-day readmissions and lower 30-day postdischarge mortality and conclude that efforts to reduce readmissions for the analyzed conditions do not lead to increased mortality. A previous WebM&M commentary discussed an incident involving a patient readmitted to the hospital after being discharged to a skilled nursing facility.
Perlo J, Balik B, Swensen S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
Leadership has a responsibility to establish a culture that fosters staff and clinician well-being as a key component of patient safety. This white paper highlights the importance of enabling joy at work, reviews examples of organizations that have tested strategies to improve joy in work, and provides measurement tools to monitor the effect of initiatives over time. A past PSNet interview discussed joy in practice and physician professional satisfaction.
Hodges NL, Spiller HA, Casavant MJ, et al. Clin Toxicol (Phila). 2018;56:43-50.
Medication errors that occur in health care settings have been well described, but less is known about medication errors that take place in non–health care settings. In this retrospective study, researchers analyzed data from the National Poison Database System. Over a 13-year study period, 67,603 unintentional medication errors that resulted in serious medical outcomes occurred outside the health care setting. The study found an average rate of these types of medication errors of 1.73 per 100,000 people. Death was reported in 0.6% of cases. In keeping with prior research, the most frequently reported types of medication errors included dosing and administration errors. A previous WebM&M commentary described a near miss in which a patient almost administered the wrong medication to himself after hospital discharge.
Frank JW, Lovejoy TI, Becker WC, et al. Ann Intern Med. 2017;167(3):181-191.
Opioid medication use is associated with an increased risk of adverse drug events, including overdose-related deaths. A previous study demonstrated that patients prescribed higher doses of opioid medications or longer duration of opioid therapy were more likely to continue to use opioid medications over time. Although recent opioid prescribing guidelines recommend reducing doses and limiting duration of therapy, the impact of adherence to these guidelines on patient outcomes remains unknown. This systematic review included 67 studies involving dose reduction or discontinuation of long-term opioid therapy in patients being treated for chronic pain. Researchers conclude that the evidence on the effectiveness of interventions aimed at decreasing long-term opioid therapy and reducing doses on improving patient outcomes such as pain, function, and quality of life is limited. An accompanying editorial comments on the challenges associated with chronic pain management and acknowledges the need for further research in this area.
Chaudhary MA, Schoenfeld AJ, Harlow AF, et al. JAMA Surg. 2017;152:930-936.
The epidemic of deaths associated with opioid medications has spurred research examining clinicians' prescribing patterns. Recent studies have shown that opioids are frequently prescribed in situations where there is little evidence of their benefit—such as after dental procedures—and that there is considerable variation in prescribing rates between providers. However, the true incidence of inappropriate opioid prescribing has not yet been defined. This retrospective study of patients who had sustained traumatic injuries examined the relationship between injury severity and opioid prescribing. Investigators found that patients with more severe injuries were more likely to be prescribed opioids, indicating that opioid prescribing in this context was likely appropriate in most cases. The study and accompanying editorial emphasize the importance of targeted efforts to reduce inappropriate opioid prescribing, focusing primarily on reducing opioid use for chronic noncancer pain (where there is no evidence opioids are beneficial) while not denying opioids to those in acute pain from trauma or other reasons.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Aiken LH, Sloane D, Griffiths P, et al. BMJ Qual Saf. 2017;26:559-568.
Researchers analyzed patient discharge data and hospital characteristics, as well as patient and nurse survey data, across adult acute care hospitals in six European countries. After adjusting for hospital and patient variables, they found that hospitals in which nursing care was provided to a greater degree by skilled nurses had lower odds of mortality. The authors argue against replacing professional nurses with nursing assistants and suggest that doing so may compromise patient safety by increasing preventable deaths.
Walker S, Mason A, Quan P, et al. Lancet. 2017;390:62-72.
The weekend effect (higher mortality for patients in acute care settings on weekends compared to weekdays) has led to widespread concerns about hospital staffing. This retrospective study examined whether mortality for emergency admissions at four hospitals in the United Kingdom differed on weekends compared to weekdays. Unlike prior studies of the weekend effect, this study included multiple specific markers of patients' illness severity as well as hospital workload. Investigators found higher mortality associated with being admitted to the hospital during weekends compared to weekdays, but a significant proportion of the observed weekend effect was explained by severity of patient illness. They used three measures to approximate hospital workload: total number of admissions, net admissions (subtracting discharges from admissions), and percentage of beds occupied. None of these workload measures was associated with mortality. The authors conclude that differences in illness severity rather than health care team staffing explain the weekend effect. A recent PSNet interview discussed the weekend effect in health care.
Larsen E, Fong A, Wernz C, et al. J Am Med Inform Assoc. 2018;25(2):187-191.
When electronic health records are out of use, either for planned upgrades or because of unexpected malfunction, this downtime disrupts usual hospital workflow. This study conducted an automated text search to identify incident reports related to electronic record downtime and analyzed the selected reports. Electronic health record downtime led to issues with laboratory testing including specimen identification errors and delayed transmission of results. Medication administration errors were also prevalent during downtime. Researchers found that downtime could hinder patient identification and information availability, which may result in serious safety hazards. The authors advocate for development of more comprehensive downtime procedures to address safety concerns as well as more consistent adherence to existing procedures.
Mazurenko O, Richter J, Kazley AS, et al. Health Care Manage Rev. 2019;44:79-89.
Establishing a climate of safety is essential for improving safety in hospitals. Although a robust safety climate is associated with measurable improvements in safety, the question remains whether patients perceive their care differently in hospitals with a stronger safety culture. This cross-sectional study used data from the AHRQ Hospital Survey on Patient Safety Culture (HSPSC) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) to examine the relationship between safety culture and patient satisfaction with care. Investigators found a moderately strong association between HSPSC and HCAHPS scores, indicating that hospitals with a more robust culture of safety also had higher patient satisfaction scores. This correlation was particularly strong for the teamwork and communication domains of the HSPSC, indicating that improvement in relationships between staff may translate to enhanced communication with patients. A prior multinational study also found a positive association between nurses' perception of care quality and patient satisfaction. A recent PSNet interview discussed recent advancements in understanding safety culture.
Beauvais B, Richter JP, Kim FS. Health Care Manage Rev. 2019;44:2-9.
Experts have argued for a business case for patient safety, but studies of economic outcomes and patient safety have been mixed. This retrospective, cross-sectional study sought to determine whether hospital safety was associated with hospital financial outcomes by analyzing Leapfrog Hospital Safety Score data and American Hospital Association data on operating income, operating margin, and net patient revenue. This study included more than 2200 hospitals in the United States. After adjusting for factors affecting both safety and finances (such as hospital size, teaching status, rural versus urban location, and payer mix), investigators found that hospitals with better financial performance were likely to have a higher safety rating. The authors suggest that promoting patient safety leads to improved financial outcomes; however, it is equally possible that financially stable hospital systems invest more in preventing adverse events and promoting safety. A past PSNet perspective discussed efforts to promote the business case for patient safety.
Mody L, Greene T, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Moran D, Wu AW, Connors C, et al. J Patient Saf. 2020;16(4):e250-e254.
Medical errors and adverse events can have a devastating psychological impact on the providers involved, often referred to as second victims. Increasingly, health care institutions are implementing programs designed to provide emotional support to team members who experience emotional distress as a result of adverse events. This study provides an economic cost–benefit evaluation of the Resiliency In Stressful Events (RISE) program at Johns Hopkins Hospital. Investigators estimate a savings of $22,576.05 per nurse who used the RISE program and suggest that the hospital might save as much as $1.81 million annually as a result of RISE. These findings are consistent with a previous study, which demonstrated the positive impact of an emotional support program on work-related outcomes such as turnover intentions and absenteeism. In a past PSNet perspective, Susan Scott discussed the second victim phenomenon and its impact on health care providers.
Dykes PC, Rozenblum R, Dalal AK, et al. Crit Care Med. 2017;45.
Establishing a strong safety culture may lead to a reduction in adverse events. Many health care institutions are focused on improving multiple aspects of culture including teamwork, communication, and patient engagement to mitigate harm. In this prospective study, researchers sought to understand the impact of a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit. They included 1030 admissions in the baseline period and 1075 in the intervention period. The rate of adverse events decreased by almost 30%, from 59.0 per 1000 patient days in the baseline period to 41.9 per 1000 patient days during the intervention period. Patient and care partner satisfaction improved as well. A past PSNet perspective discussed the relationship between patient engagement and patient safety.
Martinez W, Lehmann LS, Thomas EJ, et al. BMJ Qual Saf. 2017;26(11):869-880.
Health care provider comfort with raising patient safety concerns is a critical aspect of safety culture. This survey of resident physicians at six academic medical centers demonstrated that trainees remain reluctant to speak up. Nearly half reported observing a patient safety threat. The majority spoke up about patient safety concerns, but a significant proportion did not. Although unprofessional behavior was more frequently observed, fewer trainees raised concerns about lack of professionalism than about patient safety. Even when respondents perceived the unprofessional behavior as having high potential for adverse patient consequences, they were not as likely to speak up about this compared to a traditional patient safety threat such as inadequate hand hygiene. The authors recommend specifically measuring tolerance for unprofessional behaviors as a part of safety culture assessment.
Haynes AB, Edmondson L, Lipsitz SR, et al. Ann Surg. 2017;266:923-929.
Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Schiff GD, Bearden T, Hunt LS, et al. Jt Comm J Qual Patient Saf. 2017;43:338-350.
Delayed diagnosis of colon cancer due to missed screening or follow-up leads to preventable morbidity and mortality. In this quality improvement effort, the study team sought to enhance colon cancer screening in primary care. They identified several important drivers of successful screening programs, including leadership support, patient engagement, teamwork, tracking of results, closed loops for referrals, and health information technology tools to support best practices. Sequential plan-do-study-act cycles were implemented to improve processes. Participating practices had widely varying baseline screening rates, and some sites demonstrated significant improvements from baseline while others did not change. The effort required to augment colon cancer screening in primary care demonstrates the challenge of implementing evidence-based practices in order to achieve timely diagnosis of cancer.
Brummett CM, Waljee JF, Goesling J, et al. JAMA Surg. 2017;152:e170504.
Opioid medication use represents a significant safety problem in the United States. Overprescribing by providers is one factor contributing to the widespread use of opioids. Reducing inappropriate prescribing may help improve patient safety. Using claims data for 36,177 patients, investigators sought to better characterize new and persistent opioid use after surgery, defined as filling an opioid prescription between 90 and 180 days postoperatively. Although there was no major difference in persistent opioid use between those who underwent minor surgical procedures and those who underwent major surgical procedures, results demonstrated that opioid use persisted in greater frequency after surgery among patients with behavioral, pain, and substance use disorders. A recent PSNet perspective discussed patient safety with regard to opioid medications.
Salyers MP, Bonfils KA, Luther L, et al. J Gen Intern Care. 2017;32(4):475-482.
Burnout among health care providers is highly prevalent and is a pressing patient safety concern. This meta-analysis examined the relationship of burnout to health care quality. Investigators identified 82 studies of burnout and quality or safety. Most studies were cross-sectional and measured safety and quality by self-report. In the pooled analysis, higher levels of burnout were associated with lower reported quality and safety. These relationships were present across a range of outcomes and study types. Although the effects were modest in magnitude, their consistency demonstrates the importance of addressing burnout in order to improve many aspects of patient safety. A past PSNet interview with J. Bryan Sexton discussed the relationship between burnout and patient safety.