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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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Runciman WB, Helps SC, Sexton EJ, et al. J Qual Clin Pract. 1998;18:199-211.
To provide a framework for understanding system-based problems, this study developed a classification scheme using more than 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). Using a computerized model, incidents and events were organized into a hierarchical and interrelated framework in developing a categorization “tree.” The authors describe this model in detail, present examples of this Generic Occurrence Classification (GOC) operationally, and report on results from testing the framework with different events from another reporting system. They suggest that this system offers a reliable and validated method to compare and, more important, prevent incidents and accidents from various reporting sources.
Lesar TS, Briceland LL, Delcoure K, et al. JAMA. 1990;263:2329-34.
This study analyzed nearly 290,000 medication orders during a 1-year study period to determine the rates and risk factors for prescribing errors. Results indicated an overall error rate of 3.13 errors per 1000 orders written, with the greatest rate seen between noon and 4 pm and among first-year residents. Additional data presented include classes of medication involved in errors, types of errors detected, and frequency of errors by specialty service. The authors conclude that medication errors pose a significant safety risk in teaching hospitals and that system interventions, such as appropriate monitoring of prescribing habits and educational training programs, must be emphasized.
Raju TN, Kecskes S, Thornton JP, et al. Lancet. 1989;2:374-6.
This prospective study aimed at quality assurance identified medication errors among ICU admissions over a 4-year period. The overall error rate reported per admission approached 15% with several classification types described by the investigators. Detailed accounts of error types captured and the associated extent of patient injuries are also presented. The authors suggest that the first step in quality improvement is quality assurance and that appropriate documentation and measurement of current practices may lead to prevention efforts.
Lawthers AG, McCarthy EP, Davis RB, et al. Med Care. 2000;38:785-95.
In order to validate a computerized screening method, this study determined whether ICD-9 codes used to identify complications are coded accurately and if the screening method appropriately distinguished a preexisting condition from one that developed during hospitalization. Investigators compared coding from Medicare claims with those independently reviewed for more than 1200 medical records in two states. Discussion includes full presentation of the findings for each diagnosis code as well as the estimated predictive values of the computer screening method in correctly identifying hospital complications. While the authors suggest that their method has validity for capturing most surgical complications, the screening tool fails to adequately identify enough events. They propose the addition of a timing indicator to Medicare claims to improve detection of hospital complications and validate this important quality measurement tool.
Luft HS, Bunker JP, Enthoven AC. N Engl J Med. 1979;301:1364-9.
This study evaluated nearly 1500 hospitals to determine the relationship between their mortality rates and surgical volume for 12 selected procedures. Results include detailed tables of data and illustrative graphs for each procedure, suggesting a number of clear trends. Mortality associated with open-heart surgery, vascular surgery, transurethral resection of the prostate, and coronary bypass decreased with increasing volume at a given hospital. For other procedures, the mortality curve flattened at lower volumes, and some showed no relationship between volume and mortality. Although the authors recommend caution in interpretation and provide explanations for findings, they conclude that regionalization should warrant consideration for certain procedures.
The authors of this study characterized the attributable mortality rate from anesthesia by examining the records of more than 33,000 patients receiving anesthesia during a 10-year period. Cases are categorized by the type of anesthesia given, the number of deaths recorded, and the characteristics of the patients and their indicated procedure. The authors conclude that the physical condition of patients relates most closely to the contribution of anesthesia to death. When deaths were related to the use of muscle relaxants, errors of omission or commission were always noted to be present.
Tennen H; Affleck G.
This detailed review summarizes existing evidence on how people adapt to threatening events by blaming others. Discussion includes a synthesis of past work and explanations for findings from both the psychoanalytic perspective and the social psychology literature. Based on their assessment that these explanations fall short, the authors present a different model that focuses on factors influencing the incidence of blaming others and the consequences of doing so. Their model argues for a relationship between situational factors and personal characteristics, with interpersonal and intrapersonal mediators playing a role, which ultimately leads to adaptation and blame of others. They include a discussion of limitations in their proposed model as well as recommendations for future study.
Baker R, Norton PG, Flintoft V, et al. CMAJ. 2004;170:1678-86.
Using methodology originally developed for the Harvard Medical Practice Study, the authors reviewed more than 4000 hospitalizations from 20 Canadian hospitals in order to estimate the degree of iatrogenic harm suffered by patients.  Overall, 7.5% of patients suffered at least one adverse event, of which more than one-third were felt to be preventable.  These data are similar to prior studies conducted in the United States and Australia, but (as with prior studies) reviewer agreement on the presence and preventability of errors was only moderate.
Lingard L, Espin S, Whyte S, et al. Qual Saf Health Care. 2004;13:330-4.
This study used direct observation of 48 surgical procedures to characterize deficits in communication among team members.  Problematic communication occurred in nearly one-third of all exchanges between team members, and appeared to have direct effects on patient safety through increasing tension and creating the need for workarounds.  Communication and teamwork in the operating room was the subject of a classic study of safety culture.
Chang A, Schyve PM, Croteau RJ, et al. Int J Qual Health Care. 2005;17:95-105.
The rapid increase in research and publications on patient safety following the landmark Institute of Medicine report resulted in the need for a common set of definitions and terminology for patient safety concepts.  To achieve this goal, the authors developed a taxonomy based on a systematic literature review.  The taxonomy, which has been widely accepted since its publication, consists of 5 primary classifications that can be used to classify an error:  impact, type, domain, cause, and prevention or mitigation.
Altman DE, Clancy CM, Blendon RJ. New England Journal of Medicine. 2004;351.
This commentary offers a perspective on the progress made since release of the IOM report in 1999. The authors discuss the growing number of stakeholders involved in safety and the need for both public and private sectors in shaping the next 5 years of progress. They discuss some of the success and the tremendous work that lies ahead in framing a common vision for the future of patient safety efforts. Two similar articles reflected on this 5-year period as well, one published in Health Affairs and the other in JAMA.
Wachter RM. Health Aff. 2004;23.
This commentary discusses the progress made since the IOM report by reviewing the context to the patient safety movement, how health care became so unsafe, and what broad categories have played a role in shaping the current patient safety milieu. The author, who also wrote Internal Bleeding, provides a grade for the broad categories impacting safety efforts, which include regulation, error-reporting systems, information technology, the malpractice system, and workforce and training issues. Two similar articles reflected on this 5-year period, one published in the New England Journal of Medicine and the other in the Journal of the American Medical Association.
Walshe K, Shortell SM. Health Aff (Millwood). 2004;23:103-11.
The authors analyzed case studies of serious, longstanding failures in healthcare delivery—such as the Bristol Royal Infirmary cardiac surgery scandal—to determine the nature of the system factors that resulted in patient harm.  In most cases, problems were well known, but not addressed, indicating pervasive problems with safety culture and barriers to reporting and investigation of such incidents.  The authors call for improvements in reporting and investigation mechanisms, and greater transparency in both reporting and responding to major failures.  
Howard S K, Gaba D M, Smith B E, et al. Anesthesiology. 2003;98(6):1345-1355.
This study of anesthesiology residents demonstrated that fatigue negatively impairs psychomotor functioning and mood but not measures of clinical performance. Investigators examined, scored, and analyzed the observed behaviors of 12 residents in differing states of prior sleep. The findings support the notion that fatigue can lead to errors as a result of impaired cognitive abilities even if the more difficult to measure clinical performance outcomes were less affected. These findings are the first from a comprehensive simulation study addressing the effects of provider fatigue.
Rogers AE, Hwang W-T, Scott LD, et al. Health Aff (Millwood). 2004;23(4):202-212.
This AHRQ-funded study demonstrated that the risk of error increased in association with extended work shifts, overtime, or longer than 40-hour work weeks. Using logbooks from nearly 400 nurses sampled out of a larger group from the American Nurses Association, investigators determined that an alarmingly high percentage of nurses report working extended hours. For those shifts longer than 12.5 hours, the error rate increased notably. The authors advocate for continued attention to relationships between nursing work hours and patient safety, building on past research that linked staffing to poor patient outcomes.