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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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41 - 60 of 815 Results
Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. BMJ Qual Saf. 2019;28(1):39-48.
This study developed a measure of patient safety leadership style for nurse managers. Researchers found that their measure of control-based versus commitment-based safety management was valid and reliable after testing among clinical nurses.
World Health Organization; Organisation for Economic Co-operation and Development; OECD; World Bank.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Gomes T, Tadrous M, Mamdani MM, et al. JAMA Netw Open. 2018;1(2):e180217.
Opioid use can increase risk of adverse drug events, including overdoses. Researchers utilized data from the Centers for Disease Control and Prevention to examine opioid-related deaths in the United States from 2001 to 2016. During this period, opioid-related deaths increased by nearly 350%. Overdose deaths occurred more among men than women and were most prevalent in patients aged 15 to 34 years. These findings raise concern regarding the increasing proportion of deaths associated with opioid use. The authors call for targeted prevention and harm reduction efforts among young adults to address the growing opioid-related harm in this group. A PSNet perspective discussed opioid overdose as a patient safety problem.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74(7):1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Larochelle MR, Bernson D, Land T, et al. Ann Intern Med. 2018;169(3):137-145.
Nationally, opioid overdose remains a common cause of preventable death. Treatment of opioid use disorder with opioid replacement therapy, specifically methadone or buprenorphine, is a potent but underutilized strategy for reducing opioid-related harm. Investigators employed a prospective cohort study to follow 17,568 adults who were treated in Massachusetts emergency departments for a nonfatal opioid overdose. About 15% received opioid replacement therapy in the subsequent 2 years. Patients on opioid replacement therapy were substantially less likely to die from opioids or any other cause. An accompanying editorial from leaders at the National Institute on Drug Abuse highlights strategies to increase the number of Americans offered these life-saving therapies. The editorial also notes the alarming number of patients who received prescriptions for short-acting opioids and benzodiazepines after an opioid overdose. A past Annual Perspective and PSNet perspective delineated other strategies for addressing the opioid crisis.
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. PLoS One. 2018;13(3):e0193510.
Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.

Loh E. BMJ Leader. 2018;2(2):59-63.

Artificial intelligence (AI) can improve diagnostic accuracy. Despite early enthusiasm for the utility of AI at the front line, some have raised concerns associated with legal liabilities and ethical issues. This review discusses these considerations and suggests approaches that leaders and clinicians should embrace to prepare for future integration of AI systems in practice.
Joseph A, Bayramzadeh S, Zamani Z, et al. HERD. 2018;11(2):137-150.
Elements of the work environment can affect the safety of health care delivery. This literature review summarizes research to inform architectural and interior design improvements for operating rooms that support safety. The discussion highlights environmental themes associated with layout, acoustics, and lighting that can affect teamwork, processes, and communication in the operating room.
Clark BW, Derakhshan A, Desai S. Med Clin North Am. 2018;102:453-464.
Diagnostic errors have garnered increasing attention as a contributor to patient harm. This review explores reasons for underrecognition of diagnostic errors, including cognitive biases and large-scale system weaknesses. The authors suggest emphasis on education to enhance clinical knowledge, physical examination practice, and medical history-taking skills to improve diagnosis.
Haffajee RL, Mello MM, Zhang F, et al. Health Aff (Millwood). 2018;37(6):964-974.
The opioid epidemic is a well-recognized national patient safety issue. High-risk opioid prescribing can contribute to misuse. Provider prescribing has come under increased scrutiny and several states have implemented prescription drug monitoring programs (PDMPs). Prior research suggests that such programs have the potential to reduce opioid-related harm. This study used commercial claims data to assess the impact of PDMPs implemented in four states in 2012–2013 on opioid prescribing. By the end of 2014, all four states with PDMPs demonstrated a greater reduction in the average amount of morphine-equivalents prescribed per person per quarter compared with states without these programs. One state demonstrated a decrease in the percentage of people who filled an opioid prescription. The authors conclude that PDMPs have the potential to reduce opioid use and improve prescribing practices. An Annual Perspective highlighted safety issues associated with opioid medications.
Krein SL, Mayer J, Harrod M, et al. JAMA Intern Med. 2018;178(8):1016-1057.
Infection control precautions including use of personal protective equipment (PPE) are critical for preventing transmission of infections within health care settings. This direct observation study observed frequent failures in use of PPE, including entering rooms without using PPE at all, PPE process mistakes, and slips in properly executing PPE use. The authors suggest that given the wide range of failures, a variety of strategies are needed to improve use of PPE.
Fiscella K, McDaniel SH. Amer Psychol. 2018;73(4):451-467.
Teamwork is an important element of safe care delivery. This review explores the evidence on the role of teams in ambulatory care, innovations in primary care teamwork models, and barriers to success. The authors offer recommendations to encourage team development in primary care, including defining team competencies, providing team training opportunities specific to ambulatory care, and adjusting care payment mechanisms.
Shafi S, Collinsworth AW, Copeland LA, et al. JAMA Surg. 2018;153(8):757-763.
Opioids are known to be high-risk medications. This secondary data analysis of more than 100,000 patients undergoing in-hospital surgical procedures at 21 hospitals found that about 10% experienced an opioid-related adverse drug event during their admission. Patients receiving higher dose and longer duration of opioids were more likely to experience adverse events. Patients who experienced an opioid-related adverse drug event had longer hospital stays, greater inpatient mortality risk, and a higher rate of readmissions compared to those who did not experience problems with opioid medications. The authors call for reducing opioid use in acute care, postoperative settings in order to improve patient safety. A previous WebM&M commentary emphasized the importance of stratifying risk for patients initiated or maintained on chronic opioid therapy to prevent misuse.
Bajaj K, Minors A, Walker K, et al. Simul Healthc. 2018;13:221-224.
Frontline simulations offer valuable opportunities to explore system issues, process weaknesses, and teamwork skills. This article discusses risks associated with in situ simulations and describes how to determine when simulations should be canceled, postponed, or relocated to ensure safety.
Patel P, Martimianakis MA, Zilbert NR, et al. Acad Med. 2018;93:769-774.
Semi-structured interviews of 15 surgical residents revealed that surgical trainees may feel pressured to exhibit certain characteristics they perceive as consistent with the ideal surgical personality. The authors suggest that trainee education should acknowledge the impact of the sociocultural context of the surgical environment on trainees.
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. J Alzheimers Dis. 2018;63(1):383-394.
Prior research has shown that polypharmacy in elderly patients with dementia is associated with a greater risk of functional decline. This cross-sectional study of Danish patients age 65 and older found that polypharmacy and potentially inappropriate medication use were common in this population and were more frequent among patients with dementia.
Braithwaite J. BMJ. 2018;361:k2014.
In learning organizations, leadership behavior creates a supportive learning environment where concrete processes are in place to facilitate learning and encourage creativity among employees. Published in a series of quality improvement articles, this commentary suggests that a commitment to systems thinking and innovation is needed to achieve progress. Elements of a changed approach include a reduced focus on rules and policies and an enhanced effort to consider system interactions.
Wakeman D, Langham MR. Semin Pediatr Surg. 2018;27:107-113.
Crew resource management is a strategy from aviation that has been applied in medicine to enhance teamwork. This review discusses crew resource management as a way to improve communication, establish a safety culture, and reduce morbidity and mortality in the operating room.
Lyons I, Furniss D, Blandford A, et al. BMJ Qual Saf. 2018;27:892-901.
Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.