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Classics and Emerging 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

All Classics and Emerging Classics (815)

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Classic
Horsham, PA; Institute for Safe Medication Practices: February 2019.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Kang H, Wang J, Yao B, et al. JAMIA Open. 2018;2(1):179-186.
Improved health information technology (IT) event databases are necessary to better understand safety events associated with health IT, but such databases are lacking. This study describes the use of the Food and Drug Administration Manufacturer and User Facility Device Experience database as a source to identify adverse events related to health IT. Frequently identified contributing factors to such events included hardware and software problems as well as user interface design issues.
Howard R, Fry B, Gunaseelan V, et al. JAMA Surg. 2019;154(1):e184234.
This observational study found that when patients were prescribed a higher number of opioid pills following surgery, they self-administered more pills, although most patients did consume all of the pills they received. The authors suggest collecting patient-reported opioid consumption data in order to make opioid prescribing safer.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13(1):98.
Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
Powers EM, Shiffman RN, Melnick ER, et al. J Am Med Inform Assoc. 2018;25(11):1556-1566.
Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.
Croskerry P. Med Teach. 2018;40(8):803-808.
Clinical reasoning is a complex process that can be influenced by numerous factors. This commentary reviews major factors that affect clinical reasoning such as teamwork, decision-maker characteristics, and environmental conditions. The author suggests that an adaptive rather than linear decision-making approach would support reasoning improvements to reduce diagnostic error.
Yardley I, Yardley S, Williams H, et al. Palliat Med. 2018;32(8):1353-1362.
The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care.
Ma C, Park SH, Shang J. Int J Nurs Stud. 2018;85:1-6.
Teamwork training interventions enhance both clinical outcomes and safety culture. This cross-sectional survey found hospital units that nurses rated as more collaborative had lower rates of both hospital-acquired pressure ulcers and falls. A PSNet Interview discusses how the nursing work environment affects patient safety.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96(7):498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
Ramani S, Könings KD, Mann K, et al. Acad Med. 2018;93(9):1348-1358.
Constructive feedback is a pillar of strong safety culture. Through resident and attending physicians focus groups at a single institution, investigators found that cultural emphasis on politeness and excellence hindered all parties' ability to provide honest feedback. The authors advocate for transitioning to a culture of growth, which would shift their institution toward a more just culture.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25(9):1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.

Ibrahim M; Gyuchan S; Jun GT; Robinson S. Safety Sci. 2018;106:104-120.

This literature review examined the application of system dynamics, a simulation method that incorporates qualitative and quantitative data to characterize and predict how complex systems will perform over time, to patient safety. The authors applied a human factors framework to this literature and identified several influences on safety, including supervision, external factors, and organizational culture. The authors conclude that the field of system dynamics can be applied to health care in order to improve patient safety.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Kale MS, Korenstein D. BMJ. 2018;362:k2820.
Overdiagnosis has emerged as a quality and safety concern due to its potential to result in financial and emotional harm for patients and their families. This review discusses factors that contribute to overdiagnosis in primary care including financial incentives and innovations in diagnostic technologies. The authors recommend increasing awareness about the negative consequences of unneeded screenings, clarifying the definition of overdiagnosis, and adjusting cultural expectations for testing and treatment as avenues for improvement.
Bohnert ASB, Guy GP, Losby JL. Ann Intern Med. 2018;169(6):367-375.
The opioid epidemic continues to be a pressing patient safety challenge in the United States. Many efforts have been implemented to curb opioid prescribing, such as policy initiatives and targeted feedback to individual clinicians. A major initiative was the release of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for patients with chronic pain. These guidelines (which do not apply to patients with cancer or patients receiving palliative care) called for initially using nonopioid medications and nonpharmacologic approaches to chronic pain before using opioids, prescribing immediate-release instead of long-acting medications, and avoiding use of other sedating medications. This study examined trends in opioid prescribing rates before and after the CDC guidelines were released. Investigators found that opioid prescribing overall has decreased between 2012 and 2017, but the rate of decline increased after dissemination of the CDC guidelines. Perhaps the most notable finding is that the number of high-dose opioid prescriptions declined by nearly 50% over the study period (from 683 to 356 prescriptions per 100,000 adults). An Annual Perspective discussed the causes and potential solutions to opioid overprescribing.
Committee on Improving the Quality of Health Care Globally. National Academies of Sciences, Engineering, and Medicine. Washington DC: National Academies Press; August 2018. ISBN: 9780309483087.
The seminal 2001 report, Crossing the Quality Chasm, assessed deficiencies in the quality of health care in the United States across six key dimensions of care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Crossing the Global Quality Chasm examines the human toll of poor-quality care worldwide, with a particular focus on low- and middle-income countries. The report documents health systems rife with quality and safety problems, estimating that 134 million adverse events (resulting in 2.5 million deaths) occur in hospitals in low- and middle-income countries yearly. High levels of both underuse and overuse of care are also documented in different settings. The authors give broad recommendations for strengthening health systems worldwide using the systems approach and principles of quality improvement. In addition, the report suggests modifying the original six dimensions of quality to include accessibility, affordability, and integrity.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27(12):954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Redmond P, Grimes TC, McDonnell R, et al. Cochrane Database Syst Rev. 2018;8(8):CD010791.
This systematic review identified 25 randomized controlled trials of methods to improve medication reconciliation at the time of hospital discharge, most of which involved a pharmacist-mediated intervention. Overall, there was no clear evidence that medication reconciliation interventions reduced either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in implementing effective medication reconciliation programs in real-world settings.
Lane MA, Newman BM, Taylor MZ, et al. J Patient Saf. 2018;14(3):e56-e60.
The second victim phenomenon refers to the emotional and psychological toll experienced by clinicians who are involved in an adverse event. Peer support has been shown to benefit second victims, especially if initiated promptly after an adverse event. This study describes the implementation and early effects of a second victim peer support program at an academic medical center, which involved training physicians and advanced practice providers as peer supporters. A WebM&M interview with Dr. Albert Wu discussed ways that organizations can support second victims.