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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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21 - 40 of 815 Results
Martin HA, Ciurzynski SM. Journal of emergency nursing: JEN : official publication of the Emergency Department Nurses Association. 2015;41(6):484-8.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic used to structure information sharing to avoid communication failures during handoffs. This review examines the challenges and benefits associated with SBAR use and provides a comparative assessment with other standardized communication tools in the field.
Wong A, Plasek JM, Montecalvo SP, et al. Pharmacotherapy. 2018;38(8):822-841.
Natural language processing (NLP) can efficiently analyze large narrative data sets to identify adverse events. Exploring the application of NLP to reduce medication errors, this AHRQ-funded review describes challenges associated with using NLP to extract information from clinical sources and highlights how engaging pharmacists in developing NLP systems can improve medication safety.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153(12):1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28(1):74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Carthon MB, Hatfield L, Plover C, et al. J Nurs Care Qual. 2019;34:40-46.
This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.
Gates PJ, Meyerson SA, Baysari MT, et al. Pediatrics. 2018;142(3):e20180805.
Pediatric medication errors remain an important focus of safety initiatives. This systematic review examined the extent of preventable patient harm from medication errors for pediatric inpatients. The 22 included studies reported incidence rates ranging from 0 to 74 preventable adverse drug events per 1000 inpatient days. Across all studies, most errors were minor and did not result in patient harm. Use of health information technology was associated with less harm. Emphasizing the challenges of detecting and reporting errors, a related editorial calls for standardizing descriptions of preventable adverse events and harm in pediatrics. A WebM&M commentary addressed the high potential for weight-based medication errors in pediatrics and provided recommendations to help mitigate this risk.
Gianfrancesco MA, Tamang S, Yazdany J, et al. JAMA Intern Med. 2018;178(11):1544-1547.
Machine learning, a type of computing that uses data and statistical methods to enable computers to progressively enhance their prediction or task performance over time, has been widely promoted as a tool to improve health care safety. This commentary describes the potential for machine learning to worsen socioeconomic disparities in health care. Disadvantaged populations are more likely to receive care in multiple health systems. Therefore, relevant data about their health may be missing in an individual health system's records, hindering performance of machine learning algorithms. Racial and ethnic minority patients may not be present in sufficient numbers for accurate prediction. The authors raise concern that implicit bias in the care that disadvantaged populations receive may influence algorithms, which will amplify this bias. They recommend inclusion of sociodemographic characteristics into algorithms, building and testing algorithms in diverse health care systems, and conducting follow-up testing to ensure that machine learning does not perpetuate or exacerbate health care disparities.
Doctor JN, Nguyen A, Lev R, et al. Science (1979). 2018;361:588-590.
High-risk opioid prescribing by providers contributes to opioid misuse. Prior studies have shown that patients frequently receive opioid prescriptions even if they have a history of overdose. In this randomized trial involving 861 providers prescribing opioids to 170 patients who experienced fatal overdose, providers in the intervention arm were notified about patients' deaths by the county medical examiner while those in the control arm were not. Researchers found that milligram morphine equivalents prescribed to the patients of providers who received the death notifications decreased by almost 10% in the 3-month period following the intervention. There were no significant changes in the prescribing patterns of the control group. An Annual Perspective discussed patient safety and opioid medications.
Millenson ML, Baldwin JL, Zipperer L, et al. Diagnosis (Berl). 2018;5(3):95-105.
Recently, several mobile health care applications have been developed and marketed directly to nonclinician consumers. Researchers reviewed the literature regarding direct-to-consumer diagnostic applications. They found wide variation in the safety of these applications and suggest that further research is needed to thoroughly assess their effectiveness.
Simsekler MCE, Ward JR, Clarkson J. Ergonomics. 2018;61(8):1046-1064.
In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.
Young M, Thomas A, Lubarsky S, et al. Acad Med. 2018;93(7):990-995.
Enhancing clinical reasoning skill is emerging as a strategy to reduce diagnostic error. This review spotlights the need for a uniform definition of clinical reasoning and a robust literature base to augment efforts to improve reasoning and decision making. The authors suggest these refinements will identify cognitive biases and other contextual influences on clinical reasoning and improve education and professional development.
Bell SK, Roche SD, Mueller A, et al. BMJ Qual Saf. 2018;27(11):928-936.
A critical component of strong safety culture is that patients and families feel empowered to speak up about safety concerns. Patients and families are often the first to notice changes in their well-being and consistently identify unique adverse events that are not detected through provider-driven means. This cross-sectional survey asked patients currently hospitalized in an intensive care unit (ICU) and their families about their comfort discussing safety concerns with their health care team, then validated those responses with an Internet-recruited nationwide cohort of patients and families who had been previously cared for in ICUs. Many current ICU patients and families expressed some reticence to speak up. Common reasons cited were concern that the health care team was too busy, fear of being labeled a troublemaker, and worry that the team would judge them for not understanding the medical details of their care.
Chung CP, Callahan T, Cooper WO, et al. Pediatrics. 2018;142(2):e20172156.
Reducing the incidence of opioid overdoses and overdose deaths is an essential patient safety priority. In the last decade, children have experienced a dramatic rise in hospitalizations and intensive care unit stays for opioid poisoning. Researchers examined outpatient opioid prescriptions to children who did not have serious illnesses like cancer or sickle cell disease in Tennessee between 1999 and 2014. Dentists prescribed the largest share of more than 1 million opioid prescriptions, followed by surgeons. The authors conclude that 1 in every 2611 prescriptions resulted in an emergency department visit or hospitalization. An accompanying editorial contextualizes the study findings and offers suggestions, such as relying on less toxic analgesics for dental procedures and choosing alternatives to codeine for children who need opioids. A past PSNet perspective examined the patient safety implications of the opioid epidemic.
Emerging Classic
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197(11):1389-1395.
This commentary explores the results of a multidisciplinary discussion on the intersection of "respect" and "dignity" as requirements of safe care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, which include the need to expand the research on respect in the intensive care unit and the value of responding to failures of respect as safety incidents to design mechanisms for improvement.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27(12):1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Zhou L; Blackley SV; Kowalski L; Doan R; Acker WW; Landman AB; Kontrient E; Mack D; Meteer M; Bates DW; Goss FR.
Clinical documentation is an essential part of patient care. However, in the electronic health record era, documentation is widely perceived to be inefficient and a significant driver of physician burnout. Speech recognition software, which directly transcribes clinicians' dictated speech, is increasingly being used in order to streamline the documentation workflow. This study examined the accuracy of speech recognition software in a sample of notes (progress notes, operative notes, and discharge summaries) produced by 144 clinicians of multiple disciplines in 2 health systems. Transcripts produced by speech recognition software had 7.4 errors per 100 transcribed words, with many of these errors being potentially clinically significant. Although review by a professional medical transcriptionist corrected most of these errors, about 1 in 300 words remained incorrect even in the final physician-signed note. This study corroborates prior research that found potentially significant error rates in software-transcribed emergency medicine and radiology notes. A WebM&M commentary discussed an adverse event that occurred due to a transcription error in a radiology study report.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142(2):e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Jung JJ, Jüni P, Lebovic G, et al. Ann Surg. 2020;271(1):122-127.
Analysis of errors in aviation is facilitated by the cockpit "black box," which records flight data as well as communications between team members. This study reports on initial data from the OR Black Box, a novel monitoring technology that integrates continuous monitoring of intraoperative data with video and audio recording of operative procedures. In this initial study of elective laparoscopic procedures, auditory and cognitive distractions were common, and multiple safety events occurred during each procedure.
Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018;93:1571-1580.
Physician burnout is a highly prevalent patient safety concern. Researchers employed data from the American Medical Association to survey United States physicians about burnout and safety. Of 6586 respondents, 54% reported burnout symptoms, consistent with prior studies. More than 10% of respondents reported a major medical error in the prior 3 months, and these rates were even higher among physicians that had symptoms of burnout, even after adjustment for personal and practice factors. The majority of physicians graded their work unit safety as excellent or very good. The authors conclude interventions to improve safety must address both burnout and work unit safety. Because the survey response rate was less than 20%, it is unclear whether these findings reflect practicing US physicians more broadly. An Annual Perspective summarized the relationship between clinician burnout and patient safety.