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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 (867)

1 - 20 of 41 Results
Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Sloane DM, Smith HL, McHugh MD, et al. Med Care. 2018;56:1001-1008.
Prior research suggests that improved nursing resources may be associated with decreased mortality and adverse events. However, less is known about how changes to nursing resources in the inpatient setting may affect quality and safety over time. In this study involving 737 hospitals and survey data from nurses obtained in 2006 and 2016, researchers found that after adjusting for numerous factors, better nursing resources in terms of work environment, staffing, and education was associated with improvement in quality and patient safety outcomes. A PSNet perspective discussed the impact of nursing resources on patient safety.
Aiken LH, Sloane DM, Barnes H, et al. Health Aff (Millwood). 2018;37:1744-1751.
Factors in the hospital work environment can affect nurses' ability to provide safe care. In this survey study, investigators examined trends in nurse ratings of their work environment and patient ratings of care quality at 535 hospitals between 2005 and 2016. Over this time frame, about 20% of hospitals showed significant improvements in work environment scores, while 7% of hospitals demonstrated declining scores. There was an association between an improving work environment and better patient satisfaction. The authors conclude that lack of improvement in work environments may worsen safety culture and impede efforts to enhance patient safety. A PSNet interview with Linda Aiken discussed how nurse staffing and the work environment can affect patient safety and outcomes.
Tubbs-Cooley HL, Mara CA, Carle AC, et al. JAMA Pediatr. 2019;173:44-51.
Excessive nursing workload is a known safety issue. This study examined whether nurse workload in the neonatal intensive care unit affected the quality of nursing care. Investigators measured workload using patient–nurse ratios, taking into account patient acuity, and a convenience sample of nurses also reported their perceived workload. Participating nurses were asked to report the care they provided, and missed care was defined as self-reported failure to provide any of 11 prespecified essential elements of nursing care. The authors identified a consistent association between perceived workload and missed care, suggesting that nurses' own assessments of their workload should be a safety consideration. A PSNet perspective explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
Mianda S, Voce A. BMC Health Serv Res. 2018;18:747.
Clinical leadership training and teamwork training both augment the safety of maternity care. This systematic review found that most leadership training in maternity settings used a work-based learning approach rather than simulation or classroom interventions. The authors emphasize the importance of tailoring leadership interventions to low- and middle-income countries, where this training is less common.
Schwartz SP, Adair KC, Bae J, et al. BMJ Qual Saf. 2019;28:142-150.
Burnout is a highly prevalent patient safety issue. This survey study examined work–life balance and burnout. Researchers validated a novel survey measure for work–life balance by asking participants to report behaviors like skipping meals and working without breaks. Residents, fellows, and attending physicians reported the lowest work–life balance, and psychologists, nutritionists, and environmental services workers reported the highest work–life balance. Time of day and shift length also influenced work–life balance: day shift had better scores compared to night shift, and shorter shifts had better scores than longer shifts. The work–life balance score also clustered by the work setting: individuals with different roles within a given setting (such as the intensive care unit, the emergency department, or the clinical laboratory) had more similar work–life balance. Those with higher work–life balance reported better safety culture and less burnout. The authors suggest that burnout interventions target work settings rather than individuals, because work–life balance seems to function as a shared experience within health care settings.
Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
Papadopoulos I, Koulouglioti C, Ali S. Contemp Nurse. 2018;54:425-442.
Robotics are increasingly used to assist in both complicated and routine activities in health care. Although safety hazards associated with robotic technologies have been explored in surgery, risks related to purely assistive devices is understudied. This review highlights clinician perspectives regarding assistive robots in health care and highlights infection control and reliability issues as concerns associated with their use.
Ma C, Park SH, Shang J. Int J Nurs Stud. 2018;85:1-6.
Teamwork training interventions enhance both clinical outcomes and safety culture. This cross-sectional survey found hospital units that nurses rated as more collaborative had lower rates of both hospital-acquired pressure ulcers and falls. A PSNet Interview discusses how the nursing work environment affects patient safety.
Carthon MB, Hatfield L, Plover C, et al. J Nurs Care Qual. 2019;34:40-46.
This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.
Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. BMJ Qual Saf. 2019;28:39-48.
This study developed a measure of patient safety leadership style for nurse managers. Researchers found that their measure of control-based versus commitment-based safety management was valid and reliable after testing among clinical nurses.
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.
Eriksson J, Gellerstedt L, Hillerås P, et al. J Clin Nurs. 2018;27:e1061-e1067.
Overcrowding in the emergency department can compromise patient safety. This qualitative study across five emergency departments found that nurses perceive prolonged stays in the emergency department to adversely affect both patient safety and their ability to provide high-quality care.
Melnyk BM, Gallagher-Ford L, Zellefrow C, et al. Worldviews Evid Based Nurs. 2018;15:16-25.
Although the practice of evidence-based medicine is an important strategy for improving the safety and quality of health care, consistent use of known best practices does not occur. In this study, researchers sought to assess nurse competency throughout the United States across 13 evidence-based practice competencies for nurses as well as 11 additional competencies for advanced practice nurses. They administered an anonymous online survey and received responses from 2344 nurses across 19 hospitals or health systems. In general, nurses reported a lack of competency across all 24 domains, but younger nurses and those with more training reported better competency. A recent PSNet interview discussed the role of nurses with regard to patient safety and outcomes.
Phillips JM, Stalter AM, Winegardner S, et al. Nurs Forum. 2018;2018:286-298.
Unprofessional behavior among clinicians adversely affects patient safety and the quality of care. This literature review sought to apply a systems approach to studies of workplace civility in nursing. The included studies demonstrated that rude behavior is perceived to diminish care quality, increase risk of adverse events, and worsen patient satisfaction. Researchers identified triggers for workplace incivility, such as negative organizational climate and power imbalances, as well as consequences including low self-esteem and decreased productivity. The authors note that high stress environments can foster incivility and lead to burnout. They recommend practice-based competency in civility in order to improve patient safety. A previous PSNet perspective discussed how to identify and manage problem behaviors.
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 State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Aiken LH, Sloane D, Griffiths P, et al. BMJ Qual Saf. 2017;26:559-568.
Researchers analyzed patient discharge data and hospital characteristics, as well as patient and nurse survey data, across adult acute care hospitals in six European countries. After adjusting for hospital and patient variables, they found that hospitals in which nursing care was provided to a greater degree by skilled nurses had lower odds of mortality. The authors argue against replacing professional nurses with nursing assistants and suggest that doing so may compromise patient safety by increasing preventable deaths.
Moran D, Wu AW, Connors C, et al. J Patient Saf. 2020;16:e250-e254.
Medical errors and adverse events can have a devastating psychological impact on the providers involved, often referred to as second victims. Increasingly, health care institutions are implementing programs designed to provide emotional support to team members who experience emotional distress as a result of adverse events. This study provides an economic cost–benefit evaluation of the Resiliency In Stressful Events (RISE) program at Johns Hopkins Hospital. Investigators estimate a savings of $22,576.05 per nurse who used the RISE program and suggest that the hospital might save as much as $1.81 million annually as a result of RISE. These findings are consistent with a previous study, which demonstrated the positive impact of an emotional support program on work-related outcomes such as turnover intentions and absenteeism. In a past PSNet perspective, Susan Scott discussed the second victim phenomenon and its impact on health care providers.
Westbrook JI, Li L, Hooper TD, et al. BMJ Qual Saf. 2017;26:734-742.
This randomized controlled trial had nurses on four hospital wards wear "do not interrupt" vests during medication administration. The rate of interruptions the intervention nurses experienced was compared to the rate in four control wards that did not have nurses wear vests. Although the intervention reduced non–medication-related interruptions, nurses reported that the vests were time consuming and uncomfortable; less than half would support continuing the intervention. This study demonstrates the need to design and test sustainable interventions to improve patient safety.
Vadnais MA, Hacker MR, Shah NT, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;43.
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 factors influencing the rate of nulliparous term singleton vertex (NTSV) cesarean delivery rate. The initiative consisted of provider education, provider feedback, and implementation of new policies. The rate of NTSV cesarean delivery decreased from 34.8% to 21.2% and total cesarean delivery rate decreased from 40.0% to 29.1%. Researchers also noted a decline in the incidence of episiotomy and third-degree lacerations.