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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;368:2255-2265.

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 (907)

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Displaying 1 - 20 of 905 Results
Macrae C, Draycott T. Safety Sci. 2019;117:490-500.
Simulation training can enhance teamwork, identify latent problems, and contribute to improved patient outcomes. This commentary explores the value of frontline obstetric simulation to develop high reliability. The authors discuss relational rehearsal, system structuring, and practice elaboration as elements of a successful simulation-focused organizational learning initiative.
Chen Y-F, Armoiry X, Higenbottam C, et al. BMJ Open. 2019;9:e025764.
Patients admitted to the hospital on the weekend have been shown to experience worse outcomes compared to those admitted on weekdays. This weekend effect has been observed numerous times across multiple health care settings. However, whether patient characteristics (patients admitted on the weekend may be more severely ill) or system factors (less staffing and certain services may not be available on the weekend) are primarily responsible remains debated. In this systematic review and meta-analysis including 68 studies, researchers found a pooled odds ratio for weekend mortality of 1.16. Moreover, the weekend effect in these studies was more pronounced for elective rather than unplanned admissions. They conclude that the evidence suggesting that the weekend effect reflects worse quality of care is of low quality. A past PSNet perspective discussed the significance of the weekend effect with regard to cardiology.
Braun SE, Kinser PA, Rybarczyk B. Transl Behav Med. 2019;9:187-201.
Mindfulness supports reliability, team performance, and resilience. This literature analysis assessed the evidence on how mindfulness affects patient safety, treatment outcomes, and patient-centered care. The review revealed moderate influences on the overall ability of clinicians to provide effective care, but the authors conclude that further research is needed.
Wood C, Chaboyer W, Carr P. Int J Nurs Stud. 2019;94:166-178.
Early detection of patient deterioration remains an elusive patient safety target. This scoping review examined how nurses employ early warning scoring systems that prompt them to call rapid response teams. Investigators identified 23 studies for inclusion. Barriers to effective identification and treatment of patient deterioration included difficulty implementing early warning score systems, overreliance on numeric risk scores, and inconsistent activation of rapid response teams based on early warning score results. They recommend that nurses follow scoring algorithms that calculate risk for deterioration while supplementing risk scoring with their clinical judgment from the bedside. A WebM&M commentary highlighted how early recognition of patient deterioration requires not only medical expertise but also collaboration and communication among providers.
Dowell D, Haegerich T, Chou R. N Engl J Med. 2019;380:2285-2287.
Improving opioid prescribing is a complex challenge that requires multipronged approaches to achieve safe patient pain management. This commentary offers insights to help organizations effectively implement the Centers for Disease Control and Prevention guideline and notes how misapplication of recommendations have resulted in unintended consequences such as patient harm.
Busch IM, Moretti F, Purgato M, et al. J Patient Saf. 2020;16:e61-e74.
The second victim phenomenon refers to the emotional impact adverse events and patient harm can have on health care team members, including physicians and nurses. This meta-analysis sought to quantify psychological and psychosomatic symptoms experienced by second victims. Researchers identified 18 studies and found that embarrassment, guilt, regret, self-recrimination, anxiety, fear of future errors, reliving the incident, and difficulty sleeping were the most common symptoms. These results underscore how involvement in errors can have detrimental consequences for provider well-being. The authors recommend both preventive programs and postevent support for health care workers after medical errors. A PSNet interview with Albert Wu, who coined the term second victim, discussed approaches to address this safety issue.
Bisbey TM, Reyes DL, Traylor AM, et al. Am Psychol. 2019;74:278-289.
Team development is an important focus of safety improvement. This article provides an overview of team training science and highlights aviation, military, and health care failures that motivated research to understand the psychology of teams. The authors emphasize the importance of multidisciplinary collaboration and the contributions of psychologists as research partners in this work.
Smith AF, Plunkett E. Anaesthesia. 2019;74:508-517.
Health care leaders have embraced applying safety sciences methods to improve care delivery. This review discusses the evolution of health care safety from focusing on reactive analysis and response to error (Safety-1) to one that seeks to prevent errors through emphasizing safe system design (Safety-2). The authors advocate for developing a resilient system to examine what works well and incorporate those practices into daily work.
Review
Emerging Classic
Smulyan H. Am J Med. 2019;132:153-160.
Misinterpretations of critical tests can lead to diagnostic delays and patient harm. This review suggests combining computerized and human analysis of electrocardiogram results to enhance test interpretation accuracy and effectiveness.
Commentary
Classic
Rajkomar A, Dean J, Kohane I. New Engl J Med. 2019;380:1347-1358.
Machine learning in health care is in the early stage of application. This review explores machine learning and its potential to enhance clinical decision-making as a tool for safe value-based care. The authors discuss how machine learning can affect prognosis, diagnosis, treatment, clinician workflow, and access to expertise. They describe key challenges to integrating machine learning in health care, including access to high-quality data.
Commentary
Emerging Classic
Clarkson MD, Haskell H, Hemmelgarn C, et al. BMJ. 2019;364:l1233.
The term "second victim," coined by Dr. Albert Wu, has engendered mixed responses from patients and health care professionals. This commentary raises concerns that the term negates the sense of responsibility for errors that result in harm and advocates for abandoning it.
Sutherland A, Ashcroft DM, Phipps DL. Arch Dis Child. 2019;104:588-595.
Using clinical vignettes, investigators conducted semi-structured interviews with those prescribing medications in a pediatric intensive care unit to better understand human factors contributing to prescribing errors. They found that cognitive load was the main contributor to such errors.
Arriaga AF, Sweeney RE, Clapp JT, et al. Anesthesiology. 2019;130:1039-1048.
Debriefing after a critical event is a strategy drawn from high reliability industries to learn from failures and improve performance. This retrospective study of critical events in inpatient anesthesiology practice found that debriefing occurred in 49% of the incidents. Debriefs were less likely to occur when critical communication breakdowns were involved, and more than half of crisis events included at least one such breakdown. Interviews with care teams revealed that communication breakdowns present in some incidents impeded the subsequent debriefing process. The authors call for more consistent implementation of debriefing as a recommended patient safety process. A previous WebM&M commentary discussed an incident involving miscommunication between a surgeon and an anesthesiologist.
Kaufman RM, Dinh A, Cohn CS, et al. Transfusion (Paris). 2019;59:972-980.
Wrong-patient errors in blood transfusion can lead to serious patient harm. Research has shown that use of barcodes to ensure correct patient identification can reduce medication errors, but less is known about barcoding in transfusion management. This pre–post study examined the impact of barcode labeling on the rate of wrong blood in tube errors. Investigators found that use of barcoding improved the accuracy of labels on blood samples and samples that had even minor labeling errors had an increased chance of misidentifying the patient. The authors conclude that the results support the use of barcoding and the exclusion of blood samples with even minor labeling errors in order to ensure safe blood transfusion. An accompanying editorial delineates the complex workflow, hardware, and software required to implement barcoding for transfusion. A past WebM&M commentary discussed an incident involving a mislabeled blood specimen.
Martin G, Khajuria A, Arora S, et al. J Am Med Inform Assoc. 2019;26:339-355.
This systematic review examined whether mobile technology has been shown to improve teamwork or communication in acute care settings. Few studies met methodological quality standards, but researchers conclude that mobile technology holds promise to enhance safety through improved teamwork and communication in hospital settings.
Hessels AJ, Paliwal M, Weaver SH, et al. J Nurs Care Qual. 2019;34:287-294.
This cross-sectional study examined associations between safety culture, missed nursing care, and adverse events. Investigators found significant associations between worse ratings of safety culture and more reports of missed nursing care. They recommend enhancing safety culture to reduce missed nursing care and improve safety.
Topol E. New York, NY: Basic Books; 2019. ISBN: 9781541644632.
This book explores how advancements in technology can improve decision making but may also diminish patient-centered care. The author discusses the potential of big data, artificial intelligence, and machine learning to enhance diagnosis and care delivery. A past PSNet interview with the author, Eric Topol, talked about the role of patients in the new world of digital health care.
Lynn LA. Patient Saf Surg. 2019;13:6.
Artificial intelligence (AI) technologies can improve the use of data in care delivery. This review recommends steps to enhance the use of AI in bedside care. The author highlights the need for clinicians to accept that AI tools will affect care processes and be trained to participate in AI integration on the front line.
Silber JH; Bellini LM; Shea JA; Desai SV; Dinges DF; Basner M; Even-Shoshan O; Hill AS; Hochman LL; Katz JT; Ross RN; Shade DM; Small DS; Sternberg AL; Tonascia J; Volpp KG; Asch DA; iCOMPARE Research Group.
Duty hour reform for resident physicians was implemented as a patient safety measure, but it remains controversial. The iCOMPARE study is a cluster-randomized noninferiority trial in which 63 internal medicine programs were assigned either to follow the 2011 duty hour rules or to maintain flexible resident schedules. Researchers found no significant differences in 30-day mortality or AHRQ patient safety indicators among programs with fixed versus flexible resident schedules, similar to a recent study of surgical trainees. Programs with flexible schedules had slightly higher 30-day readmission rates and higher incidence of prolonged length of stay. Overall, the authors conclude that local flexibility in resident schedules did not adversely affect patient safety. An accompanying editorial calls for eliciting patient perspectives about trainee duty hours and the therapeutic relationship between rotating physicians and the hospitalized patient. A previous PSNet interview discussed the FIRST trial, which examined how less restrictive duty hours affected patient outcomes and resident satisfaction.
Basner M; Asch DA; Shea JA; Bellini LM; Carlin M; Ecker AJ; Malone SK; Desai SV; Sternberg AL; Tonascia J; Shade DM; Katz JT; Bates DW; Even‑Shoshan O; Silber JH; Small DS; Volpp KG; Mott CG; Coats S; Mollicone DJ; Dinges DF; iCOMPARE Research Group.
This cluster-randomized trial compared an internal medicine residency schedule that adhered to 2011 duty hour regulations to a flexible schedule that maintained an overall 80-hour work week. Self-reported sleepiness and measured sleep duration did not differ by group, but residents in the flexible programs performed worse on psychomotor vigilance testing, a measure of alertness. The authors recommend implementing fatigue-management training during residency.