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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)

Displaying 1 - 20 of 92 Results
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.
Fact Sheet/FAQs
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.
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.
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.
O'Sullivan ED, Schofield SJ. J R Coll Physicians Edinb. 2018;48:225-232.
Cognitive biases can lead to unnecessary treatment and delays in diagnosis. This commentary reviews examples of bias that commonly occur in medical practice and describes debiasing tactics to help improve decision-making.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
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;169:137-145.
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.
Shafi S, Collinsworth AW, Copeland LA, et al. JAMA Surg. 2018;153:757-763.
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.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25:385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
Amjad H, Roth DL, Sheehan OC, et al. J Gen Intern Med. 2018;33:1131-1138.
This observation study found that patients who met criteria for dementia using objective assessments often lacked a formal dementia diagnosis, even when they regularly received medical care. Many patients who were diagnosed with dementia were not aware of their diagnosis. These results indicate the need to improve both diagnosis of dementia and communication regarding dementia diagnosis.
Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Liberman AL, Newman-Toker DE. BMJ Qual Saf. 2018;27:557-566.
Patient safety measurement remains challenging. This article describes a framework to address gaps in measuring diagnostic error. The authors propose utilizing big data to develop diagnostic performance dashboards and benchmarking tools that support proactive learning and improvement strategies.
Olson APJ, Graber ML, Singh H. J Gen Intern Med. 2018;33:1187-1191.
Research is increasingly focusing on diagnostic errors and strategies to reduce them. The challenges of measuring diagnostic difficulties has hindered progress. This commentary outlines a conceptual approach to identifying "undesirable diagnostic events." The authors propose developing a list of clinical contexts and specific diseases prone to diagnostic error. Candidate conditions should be diagnosable in routine practice with a clear reference standard and defined diagnostic process. They also contend that measures should be constructed for relatively common conditions that are often misdiagnosed and for which delayed diagnosis could lead to harm, such as delayed cancer diagnosis. The authors propose designing and testing diagnosis measures based on this framework. A previous PSNet perspective by the senior author, Hardeep Singh, discussed momentum in the field of diagnostic error over the past several years.
Jones PM, Cherry RA, Allen BN, et al. JAMA. 2018;319:143-153.
Handoffs between providers are inevitable and are known to introduce risks. This retrospective population-based cohort study in Canada examined the effects of intraoperative handoffs between anesthesiologists on major complications, readmissions, and 30-day mortality among patients undergoing surgery. After adjustment for patient and site characteristics, patients who experienced an anesthesiologist handoff had higher rates of major complications and mortality compared to patients who had the same anesthesiologist throughout their procedure. The number of surgeries in which a handoff occurred increased over time during the 6-year study period. These results suggest that limiting intraoperative anesthesiologist handoffs may improve safety. However, a related editorial posits that reducing handoffs is a simplistic solution that may have unintended consequences and instead recommends that quality improvement approaches, such as developing standardized handoff procedures, may result in more meaningful enhancements for intraoperative anesthesia safety.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Bhise V, Rajan SS, Sittig DF, et al. J Gen Intern Med. 2018;33:103-115.
Recognizing and measuring diagnostic error can be challenging, which hinders efforts to study and improve diagnosis. This systematic review of 123 studies sought to characterize diagnostic uncertainty. Despite the lack of an explicit definition in any study, researchers identified diagnostic uncertainty as a clinician perception that affects diagnostic evaluation and changes over time. Strategies to measure diagnostic uncertainty included assessing clinician perceptions through survey or interview methods, examining the diagnostic evaluation through medical record review, or employing simulation with standardized cases or vignettes. The authors propose the following definition of diagnostic uncertainty: "subjective perception of an inability to provide an accurate explanation of the patient's health problem," paralleling the National Academy of Medicine's definition of diagnosis. A recent WebM&M commentary discussed how cognition influences diagnostic decision-making.
Thiels CA, Anderson SS, Ubl DS, et al. Ann Surg. 2017;266:564-573.
Opioid-related mortality is a patient safety concern. Prior studies have demonstrated that postdischarge opioid prescribing can lead to chronic use in opioid-naïve patients. This retrospective observational study examined the amount and duration of opioid prescribing following 25 common elective surgical procedures. Nearly all patients were prescribed opioids after elective surgery. The median amount of opioids prescribed, 375 oral morphine equivalents, was nearly twice the maximum recommended. Quantity of opioids prescribed differed by sex, body weight, age, and diagnosis, and there were also significant variations among the three institutions included in the study. The authors call for standardizing and optimizing postsurgical opioid prescribing.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Dekker S. Boca Baton, FL: CRC Press; 2017.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.