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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 37 Results
Barr D, Epps QJ. J Thromb Thrombolysis. 2019;47:146-154.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
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.
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.
Organizational Policy/Guidelines
Emerging Classic
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. Am J Health-Syst Pharm. 2018;75:1493-1517.
Pharmacists can play an important role in medication error reduction efforts across health care systems. This document provides recommendations and best practices for health-system pharmacists to improve safety throughout the medication-use process.
Scott IA, Pillans PI, Barras M, et al. Ther Adv Drug Saf. 2018;9:559-573.
The prescribing of potentially inappropriate medications is a quality and safety concern. This narrative review found that information technologies equipped with decision support tools were modestly effective in reducing inappropriate prescribing of medications, more so in the hospital than the ambulatory environment.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Escudero-Vilaplana V, et al. J Eval Clin Pract. 2019;25:28-35.
Pharmacy robots are now commonly used in hospitals for dispensing medications. Conducted at a Spanish hospital, this study found that use of pharmacy robots reduced medication dispensing errors and improved staff efficiency. The role of a pharmacy robot in a serious medication error is explored in a book that examined the effects of technological change on the health care system.
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. PLoS One. 2018;13:e0193510.
Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.
Kristensen RU, Nørgaard A, Jensen-Dahm C, et al. J Alzheimers Dis. 2018;63:383-394.
Prior research has shown that polypharmacy in elderly patients with dementia is associated with a greater risk of functional decline. This cross-sectional study of Danish patients age 65 and older found that polypharmacy and potentially inappropriate medication use were common in this population and were more frequent among patients with dementia.
Kim BY, Sharafoddini A, Tran N, et al. JMIR Mhealth Uhealth. 2018;6:e74.
Patients are powerful allies in improving medication safety. This study found that available mobile applications that enable patients to check for drug–drug interactions are of moderate quality and low cost. They did not assess efficacy. An Annual Perspective examined other technological innovations for engaging patients in safety.
Lin CA, Shah K, Mauntel LCC, et al. Am J Health Syst Pharm. 2018;75:153-158.
Errors in medication delivery can result in patient harm. This commentary introduces use of drones as a way to improve patient access to medications. The authors outline regulatory and safety factors that stakeholders seeking to utilize drone technology should consider.
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. JAMA Intern Med. 2018;178:375-382.
Preventable harm is common during and after hospital discharge. Pharmacist-delivered medication reconciliation has been proposed as a strategy to reduce adverse medication events and readmissions. Investigators conducted a three-arm randomized controlled trial comparing the effect of pharmacist-delivered medication reviews, motivational interviews, and postdischarge follow-up with nursing homes, primary care providers, and pharmacies (extended intervention); simple inpatient medication reconciliation (basic intervention); and usual care (no intervention) on outcomes for medically complex patients. The extended intervention reduced hospital readmissions and emergency department visits within 180 days of discharge while the basic intervention did not. This trial was large, robustly conducted, and demonstrated a durable improvement in safety for patients at increased readmission risk. A previous Annual Perspective explored tools for safer transitions of care.
Shah A, Hayes CJ, Martin BC. MMWR Morb Mortal Wkly Rep. 2017;66:265-269.
Opioid use has become a growing patient safety concern. Recent studies have documented wide variation in opioid prescribing for acute pain and a significant rate of chronic opioid use after patients receive a first prescription for an acute indication. This retrospective medical record review study identified risk factors for remaining on an opioid medication for more than 1 year following their initial prescription. Older, female, and publicly or self-insured patients were more likely to remain on an opioid compared with younger, male, and privately insured patients. Patients started on higher doses (cumulative dose ≥ 700 mg morphine equivalent), provided prescriptions with longer duration (more than 10 days), or given 3 or more prescriptions for opioids were most likely to continue to use opioid medications 1 year later. The authors recommend prescribing fewer than 7 days of opioids for acute pain and adhering to the Centers for Disease Control and Prevention guideline for opioid use to improve prescribing practices.
Schiff GD, Amato MG, Eguale T, et al. BMJ Qual Saf. 2015;24:264-71.
This study used a two-stage approach to analyze the effectiveness of computerized provider order entry (CPOE) at preventing medication errors in real-world settings. The investigators analyzed data from the MEDMARX database in order to identify the types of medication errors caused by computerized order entry. From these data, the researchers developed 21 examples of problematic orders and tested whether they could be entered in a range of commercial CPOE systems. The majority of orders were entered successfully and quickly, without the CPOE system generating any alerts or requiring clinicians to use only minor workarounds to enter the order. Even when the CPOE system did generate an alert, these could generally be overridden by clinicians without changing the order. The study findings mirror those of a prior simulation study and highlight the importance of real-world usability testing for health information technology. Although CPOE systems have been shown to reduce prescribing errors, this study's results indicate that the safety benefits of CPOE may not be achieved without careful implementation and ongoing evaluation.
Kripalani S, Roumie CL, Dalal AK, et al. Ann Intern Med. 2012;157:1-10.
Hospital discharge remains a particularly vulnerable time for adverse drug events, despite the use of medication reconciliation and other strategies to prevent medication errors at discharge. Previously, pharmacist involvement has also been shown to be beneficial in reducing medication errors, and even led to decreased readmissions in at least one study. However, in this randomized, controlled trial, approximately 50% of adult patients who received a robust pharmacist-driven intervention still experienced a clinically important medication error within one month following discharge for an episode of acute coronary syndrome or acute decompensated heart failure. The four-component intervention included pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. A case of a preventable readmission due to a medication error is discussed in this AHRQ WebM&M commentary.
Mueller SK, Sponsler KC, Kripalani S, et al. Arch Intern Med. 2012;172:1057-69.
Medication reconciliation was reinstated as a Joint Commission National Patient Safety Goal in 2011, with the goal of reducing adverse drug events (ADEs) due to inadvertent medication discrepancies. However, a lack of proven medication reconciliation strategies has resulted in frustrating experiences for many hospitals attempting to meet this requirement. This systematic review identified 26 studies of hospital-based medication reconciliation efforts, the majority of which relied on pharmacists or information technology–based interventions. Although pharmacist-led interventions and interventions focusing on high-risk patients were generally successful at reducing potential ADEs, the authors concluded that the overall literature base was insufficiently rigorous to draw firm conclusions about which strategies are both effective and generalizable.
Avery AJ, Rodgers S, Cantrill JA, et al. Lancet. 2012;379:1310-9.
Pharmacists continue to play a critical role in reducing medication errors. Past studies have focused on their impact in emergency departments and hospital settings, as well as their impact on the discharge process and specialized services. This study implemented a pharmacist-led information technology intervention (PINCER) composed of feedback and educational outreach to a randomized subset of 72 primary care practices in the United Kingdom. At 6 months following the intervention, patients in the PINCER group experienced substantially reduced frequency of clinically important prescription (e.g., beta blocker in a patient with asthma) and medication monitoring errors (e.g., ACE inhibitor in an elderly patient without assessing electrolytes). The authors suggest that their intervention can be of increasing value to other health systems that are moving towards computerized electronic health records. A past AHRQ WebM&M perspective discussed preparing pharmacists for the future in patient safety.
Nanji KC, Rothschild JM, Salzberg C, et al. J Am Med Inform Assoc. 2011;18:767-73.
Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the lack of computerized systems that promote safe prescribing. This retrospective cohort study analyzed nearly 4000 computer-generated prescriptions over a 4-week period and found a 12% error rate; 35% were considered potential adverse drug events. The error rates varied for different computerized systems (ranging from 5% to 38%) with omitted information the most common error type (60%). The findings suggest that implementing e-prescribing solutions requires more than simply adopting a computerized system. Careful attention is required to assure safe processes and functionality.
Schiff GD, Galanter WL, Duhig J, et al. Arch Intern Med. 2011;171:1433-1440.
Strategies to prevent medication errors are an ongoing focus in patient safety. Computerized provider order entry, medication reconciliation, avoidance of drug–drug interactions, and bar-coded medication administration are a few areas generating significant attention. This review discusses an alternate approach to medication safety, focusing on prevention of prescribing unnecessary medications at the outset. The authors provide a set of principles that urge clinicians to: think beyond drugs, practice more strategic prescribing, maintain heightened awareness about side effects, exercise skepticism about new drugs, work with patients for a shared agenda, and consider long-term impacts of medications prescribed. Each of these principles is discussed and sets the background for a recommendation to shift current paradigms in prescribing from "newer and more is better" to "fewer and more time tested is best."
Hamilton H, Gallagher P, Ryan C, et al. Arch Intern Med. 2011;171:1013-9.
Many medications, particularly sedatives and other drugs with significant side effects, are considered inappropriate for prescribing in elderly patients. However, the existing Beers criteria for appropriateness lack predictive power for adverse drug events. This prospective cohort study reports on the validation of the STOPP criteria, a novel list of medications considered inappropriate for elderly patients. Patients who received medications considered inappropriate by STOPP had a nearly two-fold increased odds of an adverse drug event during hospitalization, while the Beers criteria failed to predict medication errors. Given the recognized limitations of the Beers criteria, the STOPP criteria likely represent a superior method of identifying dangerous medications in geriatric patients.
Poon EG, Keohane CA, Yoon CS, et al. New Engl J Med. 2010;362:1698-1707.
Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Barcoding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a closed-loop system that combined CPOE, barcoding, and an electronic medication administration record in an academic medical center and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.