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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 80 Results
Carayon P, Wooldridge A, Hose B-Z, et al. Health Aff (Millwood). 2018;37:1862-1869.
System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.
Vento S, Cainelli F, Vallone A. World J Clin Cases. 2018;6:406-409.
Malpractice concerns can influence treatment decisions as clinicians seek to avoid errors of omission. This commentary reviews factors that contribute to defensive medicine, underscores the role the blame culture has in perpetuating this behavior, and discusses the costs to patients, physicians, and health systems.
Lam MB, Figueroa JF, Feyman Y, et al. BMJ. 2018;363:k4011.
Accreditation is a widely accepted strategy for ensuring hospital quality and safety. Hospitals accredited by The Joint Commission have been found to have improved performance on care quality metrics. However, few researchers have investigated whether or how accreditation affects patient outcomes. Investigators used Medicare data to assess the relationship between Joint Commission accreditation, other independent accreditation, or state survey review only (no independent accreditation) on patient outcomes and experience. Surgical mortality and readmissions did not differ between hospitals with and without accreditation. For medical conditions, accredited hospitals had a lower readmission rate but no statistically significant difference in mortality rate. Patient experience was modestly better at hospitals without accreditation. These findings may reflect how state survey and independent accreditation have converged in terms of methods and efficacy. A PSNet interview with The Joint Commission's CEO discussed the organization's efforts to use accreditation as one of many tools to promote high reliability in health care.
Bates DW, Landman A, Levine DM. JAMA. 2018;320:1975-1976.
Mobile health care applications are increasingly being developed and marketed to patients for self-care and diagnosis, with little oversight as to their effectiveness or safety. This commentary outlines four key issues that must be addressed to improve the safety of medical applications.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
World Health Organization; Organisation for Economic Co-operation and Development; OECD; World Bank.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient 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.
Gupta A, Allen LA, Bhatt DL, et al. JAMA Cardiol. 2018;3:44-53.
Readmissions are a focus of patient safety efforts, especially in light of Medicare's nonpayment policy. This retrospective, interrupted time-series analysis examined whether reduction in readmissions for heart failure led to any change in health outcomes. This study analyzed data from a national clinical registry of patients with heart failure admitted between 2006 and 2014, spanning the implementation of Medicare nonpayment. Similar to prior studies, there was a decline in readmission rates observed after implementation of penalties. In this cohort, researchers also observed increases in 30-day and 1-year risk-adjusted mortality. The authors conclude that penalties for readmissions may have unintended negative consequences for patient outcomes. A previous PSNet interview discussed the benefits and limitations of Medicare's nonpayment policy.
Battles J; Azam I; Grady M; Reback K; Agency for Healthcare Research and Quality; AHRQ.
This publication describes the results of demonstration projects funded by AHRQ's Patient Safety and Medical Liability Reform Initiative. Included studies examined communication and resolution programs, patient reporting of adverse events, and patient perceptions of error disclosure. An overarching theme of these studies is the gap between recommended communication practices and usual clinical care and communication. Several studies demonstrated challenges of implementing health system interventions to improve safety across a range of interventions, including error disclosure training, shared decision-making, and medication safety during transitions in care. These studies reveal the importance of measuring and improving safety culture as a foundation for patient safety efforts. Commentaries by various patient safety experts highlight the need for ongoing support for research at the intersection of patient safety and medical liability. A past PSNet perspective described how evidence-based improvements to the medical liability system could influence accountability and compensation for errors.
Gupta A, Snyder A, Kachalia A, et al. BMJ Qual Saf. 2017;27:53-60.
Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy studies, but the continuing decline in autopsy rates necessitates identification of diagnostic errors through other data sources. In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and severity of inpatient diagnostic error and estimate the clinical and economic consequences of these errors. Diagnostic error accounted for 22% of paid malpractice claims over a 12-year period, resulting in $5.7 billion in payments, and the incidence of claims due to failure to diagnose increased over time. Paid claims due to diagnostic error were more likely to be for male patients older than 50, compared with other types of paid claims. Consistent with other studies, a small proportion (9%) of physicians accounted for a large proportion (51%) of payments. Although paid malpractice claims data have important limitations, this study advances our understanding of the epidemiology of diagnostic error among hospitalized patients and insights into possible preventive mechanisms.
Dharmarajan K, Wang Y, Lin Z, et al. JAMA. 2017;318:270-278.
Reducing hospital readmissions is a major patient safety priority. The Centers for Medicare and Medicaid Services policy of nonpayment for readmissions for certain conditions has decreased their incidence. However, the impact of this policy on 30-day postdischarge mortality remains unknown. Researchers conducted a retrospective study of Medicare fee-for-service patients admitted to hospitals with heart failure, acute myocardial infarction, or pneumonia from 2008 through 2014. They calculated monthly 30-day risk-adjusted readmission rates and 30-day risk-adjusted mortality rates for each condition at each hospital. They then examined the association between hospitals' monthly trends in 30-day readmissions and 30-day mortality after discharge for each condition. The authors found a weak but significant association between decreased 30-day readmissions and lower 30-day postdischarge mortality and conclude that efforts to reduce readmissions for the analyzed conditions do not lead to increased mortality. A previous WebM&M commentary discussed an incident involving a patient readmitted to the hospital after being discharged to a skilled nursing facility.
Schaffer AC, Jena AB, Seabury SA, et al. JAMA Intern Med. 2017;177:710-718.
This retrospective study of a claims database found that medical malpractice claims declined significantly between 1992 and 2014, but mean payment amounts increased at the same time. Diagnostic error was the overall most common reason for a claim, affirming the importance of improving diagnosis.
Gellad WF, Good CB, Shulkin DJ. AMA Intern Med. 2017;177:611-612.
Opioid medications are a known safety hazard, and overdoses of opioid medications are considered an epidemic in the United States. This commentary discusses US Veterans Affairs health system initiatives that focus on education, prescription monitoring, pain management, and use of guidelines to reduce risks associated with opioids.
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.
Wasfy JH, Zigler CM, Choirat C, et al. Ann Intern Med. 2017;166:324-331.
Reducing hospital readmissions is an important patient safety objective. This pre–post study examined rates of hospital readmissions before and after the Centers for Medicare and Medicaid Services (CMS) enacted its nonpayment policy. Investigators separated hospitals into tiers of performance, considering hospitals with lowest readmission rates to be the highest performers. They found that across all levels of hospital performance, readmission rates for acute myocardial infarction, congestive heart failure, and pneumonia decreased after the Medicare Hospital Readmissions Reduction Program was introduced. Hospitals with the lowest performance prior to the nonpayment policy improved the most. These data are consistent with previous studies demonstrating the profound safety improvement following CMS nonpayment policies. A previous WebM&M interview discussed the potential benefits and limitations of insurers not paying for preventable complications.
Meara E, Horwitz JR, Powell W, et al. N Engl J Med. 2016;375:44-53.
Growing rates of opioid misuse endanger public health. The impact of legal restrictions to limit high-risk prescribing and resultant adverse events is unclear. One recent study found that opioid-related adverse events were effectively reduced in states with stringent prescription drug monitoring programs compared to states without such regulations. However, this study examined data regarding Medicare beneficiaries with disabilities before and after adoption of controlled-substance laws and found no significant decrease in rates of nonfatal overdose, high opioid doses, or receipt of opioids from four or more prescribers. These results suggest that current regulatory policy may not be sufficient to address high-risk prescribing practices among Medicare beneficiaries with disabilities. More work is needed to develop effective strategies to treat chronic pain safely in this high-risk population. A WebM&M commentary described risks related to prescribing opioids for patients with chronic pain.
Patrick SW, Fry CE, Jones TF, et al. Health Aff (Millwood). 2016;35:1324-1332.
Opioid medications carry high risk for adverse drug events, and increases in opioid abuse have led to an epidemic of overdose deaths. State-level prescription drug monitoring programs are intended to identify high-risk prescribing and patient behaviors associated with opioids. This study used secondary data sources to determine whether implementing a drug monitoring program decreased opioid overdose deaths compared to the pre-implementation period. States with more complete and timely opioid monitoring achieved greater overdose reductions compared to states with less comprehensive programs. These results clearly support universal implementation and strengthening of state prescription drug monitoring programs. A WebM&M commentary discussed a death due to an opioid overdose.
Dreischulte T, Donnan P, Grant A, et al. N Engl J Med. 2016;374:1053-64.
Adverse drug events among outpatients are common and can lead to preventable complications. Conducted in primary care practices, this cluster-randomized trial found that a combination of professional education, electronic health record alerts, and financial incentives for practices to review potentially inappropriate prescribing decreased high-risk medication prescriptions. Investigators also observed a decrease in two of the three medication-related complications associated with use of high-risk medications, suggesting a clinical benefit to this intervention. The success of this study argues for similar larger-scale, multi-modal patient safety studies to detect modest but significant improvements.
Zuckerman RB, Sheingold SH, Orav J, et al. N Engl J Med. 2016;374:1543-51.
The Centers for Medicare and Medicaid Service's policy on nonpayment for certain hospital readmissions has reduced their incidence. However, this policy change may have unintended consequences. One possible outcome is an increased number of patients who return to the hospital being placed on observation status. Comparing readmission rates and observation stays for targeted and nontargeted conditions, this secondary data analysis examined how observation stay rates changed in parallel with readmission rates. The authors found that readmissions decreased, consistent with prior studies, and observation stays increased. Interestingly, a within-hospital analysis determined that the decline in readmissions was not explained by an increase in observation stays. This finding should allay concerns about this specific unintended consequence of the readmission policy, although other issues such as length of stay changes should be addressed.
Studdert DM, Bismark MM, Mello MM, et al. New Engl J Med. 2016;374:354-362.
A growing body of research has begun to assess the role of individual clinicians in patient safety, seeking to identify clinicians whose patients are at elevated risk of adverse events. Examining data on paid malpractice claims from the National Practitioner Data Bank over a 10-year period, this study found that 1% of physicians accounted for 32% of paid claims. Moreover, recidivism was common, in that practitioners with more than 3 claims had a 24% risk of another claim within the next 2 years. As in prior studies of malpractice data, surgeons and obstetricians were more likely to have paid a claim than internists. The pattern of a relatively small number of physicians incurring repeated claims, which mirrors data from studies of patient complaints, implies that it may be possible to identify clinicians who are at high risk of subsequent malpractice claims or patient complaints. The issues around such high-risk physicians are discussed in a previous WebM&M perspective.