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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
Oakes D. ASQ Quality Press; 2019. ISBN: 978-0-87389-982-6.
Root cause analysis is a widely used patient safety and quality improvement process for investigating adverse events. This book includes detailed steps to identify system-level causes including how to use diagrams... Read More
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... 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... 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... Read More
All Classics and Emerging Classics (970)
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McKinney SM, Sieniek M, Godbole V, et al. Nature. 2020;577:89-94.
Research has found that artificial intelligence (AI) can improve diagnostic accuracy, but less is known about its performance in clinical settings. To evaluate the performance of AI in identifying breast cancer in a clinical setting, this study deployed AI in a curated, representative data set from the UK (25,856 women) and an enriched dataset from the US (3,097 women), as well as compared the performance of AI to that of six human radiologist readers. They used biopsy-confirmed cancer patients to evaluate AI predictions. The authors reported a reduction in both false positives and false negatives using AI and found that the AI system was more accurate than the radiologists.
Study
Emerging Classic
Agarwal S, Bryan JD, Hu HM, et al. JAMA Netw Open. 2019;2:e1918361.
In 2016, the Centers for Disease Control and Prevention (CDC) issued opioid prescribing guidelines that recommended limiting the duration of therapy for acute pain. Research has found that the guidelines have changed opioid prescribing in the emergency department, but less is known about the impact on postoperative opioid prescribing. This study examined the effect of opioid prescribing duration limits in Massachusetts and Connecticut on postoperative prescribing. Dosing duration limits resulted in decreases in postoperative prescription size and days supplied in Massachusetts but not in Connecticut.
Study
Emerging Classic
El Hechi MW, Bohnen JD, Westfal M, et al. J Am Coll Surg. 2019;230:926-933.
This paper describes the implementation of a "second victim" peer-support program in the surgery department at a tertiary care center. The program trained surgical attendings and trainees to provide peer-support for other surgeons involved in major adverse events. After one-year follow-up, 81% of affected surgeons elected to receive peer support. The majority (81%) felt the program had a positive impact on safety culture by providing a confidential, safe, and timely intervention for so-called "second victims". A 2011 Perspective on Safety with Dr. Albert Wu discussed ways that organizations can support "second victims."
Study
Emerging Classic
Kemper KJ, Schwartz A, Wilson PM, et al. Pediatrics. 2020;145:e20191030.
Physician burnout has been associated with increased patient safety incidents. A recent national survey of pediatric residents found burnout rates exceeded 50%. The survey found that risk of burnout was associated with reported stress, sleepiness, dissatisfaction with work-life balance and recent medical error. Burnout rates were lowest among residents reporting empathy, self-compassion, quality of life, and confidence in providing compassionate care.
Rehder KJ, Adair KC, Hadley A, et al. Jt Comm J Qual Saf. 2020;46:18-26.
This study used a brief survey to evaluate disruptive behaviors in one large health system, and its relationship to safety culture. Disruptive behaviors (most commonly bullying and inappropriate discontinuation of communication, such as hanging up the phone) were noted by more than half of individuals surveyed and occurred in nearly all work settings. Greater exposure to disruptive behaviors was associated with poorer teamwork climate, safety climate, and job satisfaction
O’Mahony D. Expert Rev Clin Pharmacol. 2019;13:15-22.
STOPP (Screening Tool of Older Persons' Prescriptions) and START (Screening Tool to Alert to Right Treatment) are criteria used as a tool for clinicians to review potentially inappropriate medications in older adults and have been endorsed as a best practice by some organizations. This article, written by the developer of STOPP/START, describes its history and updates, and current large-scale trials involving the use of specialty software that automates the process as a potential patient safety improvement.
Rozenblum R, Rodriguez-Monguio R, Volk LA, et al. Jt Comm J Qual Patient Saf. 2019;46:3-10.
Clinical decision support (CDS) tools help identify and reduce medication errors but are limited by the rules and types of errors programmed into their alerting logic and their high alerting rates and false positives, which can contribute to alert fatigue. This retrospective study evaluates the clinical validity and value of using a machine learning system (MedAware) for CDS as compared to an existing CDS system. Chart-reviewed MedAware alerts were accurate (92%) and clinically valid (79.7%). Overall, 68.2% of MedAware alerts would not have been generated by the CDS tool and estimated cost savings associated with the adverse events potentially prevented via MedAware alerts were substantial ($60/drug alert).
Levine KJ, Carmody M, Silk KJ. J Nurs Manag. 2019;28:130-138.
Medical errors occur frequently but there is great variability in whether they are reported. Focus groups and one-on-one interviews were used in this study to determine the effect of hospital culture and climate on employee decisions to speak up–or not–about medical errors. The authors conclude that their results, gathered from a large hospital in a mid-sized city in the midwestern U.S., indicate this hospital’s culture does not facilitate reporting of medical errors and suggest that creating a positive organizational culture can both promote speaking up about medical errors and increase patient safety.
Pereira-Lima K, Mata DA, Loureiro SR, et al. JAMA Netw Open. 2019;2:e1916097.
This systematic review and meta-analysis of 11 studies with a valid measure of physician (n=21,517) depressive symptoms found that physicians who screened positive for depression were associated with medical errors. The authors also conducted a meta-analysis of 7 longitudinal studies, which revealed there was a bidirectional association between physician symptoms of depression and medical errors. This finding implies that physicians that screen positive for depressive symptoms have a higher risk for medical errors. The authors recommend that future studies need to focus on whether interventions to reduce physician depressive symptoms could play a role in reducing medical errors and improving safe patient care.
Alghamdi AA, Keers RN, Sutherland A, et al. Drug Saf. 2019;42:1423-1436.
The prevalence and nature of medication errors and preventable adverse drug events in pediatric and neonatal intensive care units were examined in this systematic review. In the 35 quantitative studies included in the review, prescribing and medication administration errors were the most common errors reported, with dosing errors the most frequent subtype, in both types of critical care units. The authors concluded that critically ill children admitted to intensive care units frequently experience medication errors and identified important targets to guide remediation efforts.
Hu Y-Y, Ellis RJ, Hewitt B, et al. New Engl J Med. 2019;381:1741-1752.
Physician burnout can negatively impact not only physician well-being, but patient safety as well. This national survey of general surgery residents found that about one-third of all respondents reported experiencing discrimination or abuse; 38.5% of residents reported weekly burnout systems and 4.5% reported suicidal thoughts within the past year. Residents reporting burnout or suicidal thoughts were more likely to have experienced discrimination, abuse or sexual harassment. Women reported more exposure to mistreatment, which may account for gender differences in rates of burnout and suicidal thoughts.
Schmutz JB, Meier LL, Manser T. BMJ Open. 2019;9:e028280.
Effective teamwork is a critical component of care coordination and patient safety. This systematic review assessed the relationship between teamwork processes and clinical and process outcome measures in an acute care setting. Outcome measures included both clinical outcomes, such as postoperative infection rates, and process measures, such as adherence to checklists intended to prevent patient harm. The authors found that teamwork was positively correlated with both outcome and process measures, regardless of the characteristics of the team or task.
Review
Emerging Classic
Blenkinsopp J, Snowden N, Mannion R, et al. J Health Org Manag. 2019;33:737-756.
Staff willingness to report threats to patient safety is critical to preventing errors and improving safety and is an indicator of an organization’s safety culture. The authors discuss studies exploring what factors influence whistleblowing, organizational responses, and implications for practice or policy. The authors concluded that the existing literature focuses on the decision to speak up. There is limited evidence discussing organizational responses or systems-level changes, yet these actions influence whether the patient safety threats are addressed and if future events will be reported.
Study
Emerging Classic
O’Connell D. J Clin Outcomes Manag. 2019;26(5):213-218.
Disclosure of errors and adverse events is increasingly encouraged in health care. This article reviews disclosure and resolution pathways and discusses barriers to pathway implementation. Ensuring clinicians are equipped with tools to implement effective disclosure and fair resolution benefits both patient safety and clinician emotional well-being.
Ganguli I, Simpkin AL, Lupo C, et al. JAMA Netw Open. 2019;2:e1913325.
Cascades of care (or follow up) on incidental findings from diagnostic tests are common but are not always clinically meaningful. This study reports the results of a nationally representative group of physicians who were surveyed on their experiences with cascades. Almost all respondents had experienced cascades and many reported harms to patients and personal frustration and anxiety that may contribute to physician burnout.
National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2019. ISBN: 9780309495509.
Clinician burnout is a known contributor to unsafe care. This report summarizes evidence on the causes and impacts of clinician burnout. The authors share six recommendations for improvement which include redesign of the learning environment, technologies, and support services for clinicians.
Park M, Giap T-T-T. J Adv Nurs. 2020;76:62-80.
Patients and families are critical partners in identifying and preventing patient safety events. A systematic review found willingness among patients and families engage in safety activities, but barriers such as limited patient/family knowledge, poor communication, and lack of systems-level efforts supporting patient and family engagement may hinder effective engagement.
Garcia C de L, de Abreu LC, Ramos JLS, et al. Medicina (Kaunas). 2019;55:553.
New meta-analysis on potential impacts of provider burnout concludes a relationship exists between high levels of burnout—from factors such as high workload and ineffective interpersonal relationships—and worsening patient safety.
Review
Emerging Classic
Morgan DJ, Dhruva SS, Coon ER, et al. JAMA Intern Med. 2019;179:1568.
Medical overuse has been described as a patient safety problem among both adult and pediatric patients. Consistent with prior research, this review suggests that overtesting and overtreatment are common and have the potential to cause harm to patients.
Kroth PJ, Morioka-Douglas N, Veres S, et al. JAMA Netw Open. 2019;2:e199609.
This survey of 282 primary care physicians and ambulatory specialists found that several electronic health record design features contributed to clinician burnout, including excessive data entry requirements and long copied-and-pasted notes. However, other work environment factors (such as clinician workload) were more strongly predictive of work stress and burnout.
