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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
Vadnais MA, Hacker MR, Shah NT, et al. Jt Comm J Qual Patient Saf. 2016;43:53-61.
Cesarean delivery is associated with increased morbidity, mortality, longer hospital stays, and increased costs. From 2008 through 2015, a single tertiary care academic medical center implemented a quality improvement initiative designed to address... Read More
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United... Read More
Vaughan D. Chicago, IL: University of Chicago Press; 1996. ISBN 9780226851754.
A model of root cause analysis on a system-wide scale, Vaughan’s analysis of the Challenger crash looks beyond the widely held belief that pressure from NASA management to meet a launch schedule contributed to the decision to bypass multiple internal... Read More
All Classics and Emerging Classics (907)
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Commentary
Classic
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.
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.
Book/Report
Classic
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.
Jackson D, Sarki AM, Betteridge R, et al. Int J Nurs Stud. 2019;92:109-120.
Hospital-acquired pressure ulcers are considered never events and represent a significant source of patient harm. This systematic review and meta-analysis found a pooled incidence of 12% for pressure injuries related to the use of medical devices.
Liang H, Tsui BY, Ni H, et al. Nat Med. 2019;25:433-438.
Artificial intelligence may have the potential to improve patient safety by enhancing diagnostic capability. In this study, researchers applied machine learning techniques to a large amount of pediatric electronic health record data and found that their model was able to achieve diagnostic accuracy analogous to that of skilled pediatricians.
Rhee C, Jones TM, Hamad Y, et al. JAMA Netw Open. 2019;2:e187571.
The degree to which sepsis contributes to inpatient mortality and the extent to which sepsis-associated inpatient mortality is preventable remains unknown. In this retrospective cohort study, researchers analyzed the medical records of 568 adult patients hospitalized at 6 United States hospitals who either died during the hospitalization or were discharged to hospice. They found a diagnosis of sepsis was present in 300 cases and that it was the main cause of death in 198 cases. Reviewers rated 11 of the 300 sepsis-associated deaths as definitely or moderately likely preventable. The authors conclude that it may be challenging to further reduce sepsis-associated inpatient mortality.
Chen Q, Larochelle MR, Weaver DT, et al. JAMA Netw Open. 2019;2:e187621.
Reducing opioid-related harm is a major patient safety priority. This simulation study used a mathematical model to predict the effect of existing opioid misuse interventions on opioid overdose mortality. The researchers compared the expected decline based on the current trend over time versus the effect of a 50% faster reduction in misuse. Their calculations suggest that interventions such as prescription drug monitoring programs and insurance coverage changes will result in only a small absolute decrease in opioid overdose deaths. The authors call for developing and testing other strategies for opioid safety. An Annual Perspective discussed the extent of harm associated with opioid prescribing and described promising practices to address opioid misuse.
Fact Sheet/FAQs
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.
Chua K-P, Fischer MA, Linder JA. BMJ. 2019;364:k5092.
Prescribing unnecessary antibiotics increases the risk of resistant infections and can lead to patient harm. In this cross-sectional study, researchers found that 23% of the 15,455,834 outpatient antibiotic prescriptions filled among a cohort of 19.2 million patients over a 1-year period were consistent with inappropriate prescribing.
Hadland SE, Rivera-Aguirre A, Marshall BDL, et al. JAMA Netw Open. 2019;2:e186007.
Reducing opioid-related overdoses and deaths is a national patient safety priority. Little is known as to the extent to which direct-to-provider marketing of opioids by pharmaceutical companies influences physician prescribing and patient mortality related to overdose from prescription opioids. In this study, researchers analyzed data from both the Centers for Medicare and Medicaid Services Open Payments database and the Centers for Disease Control and Prevention on opioid prescribing and fatal overdoses at the county level within the United States from August 2014 through December 2016. They linked this to pharmaceutical company marketing data from August 2013 to December 2015. Using the Open Payments database, they found that there were 434,754 payments related to opioid marketing made to 67,507 providers across 2,208 counties accounting for almost $40 million. Further analysis revealed that marketing to providers was associated with increased prescribing of opioids and mortality from opioid overdoses. An accompany commentary concludes that numerous approaches will be necessary to effectively mitigate the opioid epidemic.
Reeve E, Wolff JL, Skehan M, et al. JAMA Intern Med. 2018;178:1673-1680.
Deprescribing or stopping unnecessary medications is an important strategy for reducing medication-related harm in older adults. A group of 1981 Medicare beneficiaries reported broad support (92%) for stopping at least one of their medications if their clinician determined it was safe. A WebM&M commentary provides in-depth recommendations to achieve safe prescribing in older patients.
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.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Kang H, Wang J, Yao B, et al. JAMIA Open. 2018;2:179-186.
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: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.
Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.
This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.
Commentary
Classic
Shortliffe EH, Sepúlveda MJ. JAMA. 2018;320:2199-2200.
Clinical decision support on the front line of care harbors both potential benefits and barriers to effective care delivery. This commentary outlines system challenges such as complexity and poor communication that hinder reliable adoption and use of clinical decision support. The authors highlight the need for research and evaluation models to help bring clinical decision support safely and effectively into daily health care work.
Magill SS, O'Leary E, Janelle SJ, et al. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13:98.
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.
