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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)

Published Date
PSNet Publication Date
1 - 20 of 302 Results
Khan A, Spector ND, Baird JD, et al. BMJ. 2018;363:k4764.
Patient engagement in safety takes many forms: patients may report unique safety incidents, encourage adherence to best medical practice, and coproduce improvement initiatives. Family-centered rounding in pediatrics invites families to express concerns, clarify information, and provide real-time input to the health care team. This pre–post study explored the safety impact of family-centered rounds on 3106 admissions in pediatric units at 7 hospitals. Family-centered rounds reduced both preventable and nonpreventable adverse events. They also improved family experience without substantially lengthening rounding time. A past PSNet interview discussed the safety benefits of structured communication between health care providers and family members.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Kang H, Wang J, Yao B, et al. JAMIA Open. 2018;2:179-186.
Improved health information technology (IT) event databases are necessary to better understand safety events associated with health IT, but such databases are lacking. This study describes the use of the Food and Drug Administration Manufacturer and User Facility Device Experience database as a source to identify adverse events related to health IT. Frequently identified contributing factors to such events included hardware and software problems as well as user interface design issues.
Steelman VM, Shaw C, Shine L, et al. Jt Comm J Qual Patient Saf. 2019;45:249-258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving 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.
Magill SS, O'Leary E, Janelle SJ, et al. N Engl J Med. 2018;379:1732-1744.
Health care–associated infections (HAIs) are a key cause of preventable harm in hospitals. Successful programs to avert HAIs include the comprehensive unit-based safety program to reduce catheter-related bloodstream infections and the AHRQ Safety Program for Surgery to prevent surgical site infections. This survey of 12,299 patients at 199 hospitals on a single day enabled researchers to estimate the prevalence of HAIs in the United States. In 2015, 3.2% of hospitalized patients experienced an HAI, a 16% decrease compared to a similarly derived estimate in 2011. The most common HAIs were pneumonia and Clostridium difficile infections, while the biggest reductions were in urinary tract and surgical site infections. This data emphasizes the importance of identifying strategies to combat pneumonia in nonventilated patients, which remains common and less well-studied than other HAIs. A past PSNet perspective discussed the history around efforts to address preventable HAIs, including federal initiatives.
Bombard Y, Baker R, Orlando E, et al. Implement Sci. 2018;13:98.
Engaging patients and their families in quality and safety is considered central to providing truly patient-centered care. This systematic review included 48 studies involving the input of patients, family members, or caregivers on health care quality improvement initiatives to identify factors that facilitate successful engagement, patients' perceptions regarding their involvement, and patient engagement outcomes.
Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.
Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.
Fisher KA, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Gates M, Wingert A, Featherstone R, et al. BMJ Open. 2018;8:e021967.
Fatigue among health care workers is a well-established safety issue that can increase risk of errors. Investigators conducted a systematic review to examine the effects of fatigue on both providers and patients, as well as the impact of efforts designed to mitigate fatigue. They ultimately included 47 studies in their analysis, 28 of which demonstrated a relationship between fatigue or inadequate sleep and physician health outcomes. Looking at six cohort studies and patient outcomes, they found no difference in patient mortality or postoperative complications between surgeons who were and were not sleep deprived. A past PSNet interview discussed how research on sleep deprivation among residents has informed duty hour changes.
Yardley I, Yardley S, Williams H, et al. Palliat Med. 2018;32:1353-1362.
The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care.
Gillespie A, Reader TW. Milbank Q. 2018;96:530-567.
Patient voices provide crucial insight into health care safety hazards. Researchers classified 1110 patient complaints submitted to England's National Health Service to identify stages of care where harm occurred. The most common cause of major or catastrophic harm was diagnostic error.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
Wick EC, Sehgal NL. JAMA Surg. 2018;153:948-954.
This systematic review of opioid stewardship practices following surgery identified eight intervention studies intended to reduce postsurgical opioid use. Organizational-level interventions such as changing orders in the electronic health record, demonstrated clear reductions in opioid prescribing. Clinician-facing interventions such as development and dissemination of local guidelines also led to reduced opioid prescribing. The authors emphasize the need for more high-quality evidence on opioid stewardship interventions.
Korenstein D, Chimonas S, Barrow B, et al. JAMA Intern Med. 2018;178:1401-1407.
Overuse of tests and treatments can contribute to negative consequences for patients. This commentary suggests that clarification is required to engage clinicians in reducing overuse-related harm and proposes a six-domain framework that delineates areas of concern to target improvement strategies. A previous WebM&M commentary highlighted a case in which health care overuse resulted in a patient's death.
Bohnert ASB, Guy GP, Losby JL. Ann Intern Med. 2018;169:367-375.
The opioid epidemic continues to be a pressing patient safety challenge in the United States. Many efforts have been implemented to curb opioid prescribing, such as policy initiatives and targeted feedback to individual clinicians. A major initiative was the release of the Centers for Disease Control and Prevention (CDC) guidelines for prescribing opioids for patients with chronic pain. These guidelines (which do not apply to patients with cancer or patients receiving palliative care) called for initially using nonopioid medications and nonpharmacologic approaches to chronic pain before using opioids, prescribing immediate-release instead of long-acting medications, and avoiding use of other sedating medications. This study examined trends in opioid prescribing rates before and after the CDC guidelines were released. Investigators found that opioid prescribing overall has decreased between 2012 and 2017, but the rate of decline increased after dissemination of the CDC guidelines. Perhaps the most notable finding is that the number of high-dose opioid prescriptions declined by nearly 50% over the study period (from 683 to 356 prescriptions per 100,000 adults). An Annual Perspective discussed the causes and potential solutions to opioid overprescribing.
Kale MS, Korenstein D. BMJ. 2018;362:k2820.
Overdiagnosis has emerged as a quality and safety concern due to its potential to result in financial and emotional harm for patients and their families. This review discusses factors that contribute to overdiagnosis in primary care including financial incentives and innovations in diagnostic technologies. The authors recommend increasing awareness about the negative consequences of unneeded screenings, clarifying the definition of overdiagnosis, and adjusting cultural expectations for testing and treatment as avenues for improvement.
Vaughn VM, Saint S, Krein SL, et al. BMJ Qual Saf. 2019;28:74-84.
The literature on effective approaches to improving quality and safety generally focuses on high reliability organizations and positive deviants—organizations or units that have achieved notable successes. This systematic review sought to characterize organizations that struggle to improve quality. The authors identified five domains that exemplify struggling organizations, including lack of a clear mission and organizational structure for improving quality and inadequate infrastructure.
Gates PJ, Meyerson SA, Baysari MT, et al. Pediatrics. 2018;142:e20180805.
Pediatric medication errors remain an important focus of safety initiatives. This systematic review examined the extent of preventable patient harm from medication errors for pediatric inpatients. The 22 included studies reported incidence rates ranging from 0 to 74 preventable adverse drug events per 1000 inpatient days. Across all studies, most errors were minor and did not result in patient harm. Use of health information technology was associated with less harm. Emphasizing the challenges of detecting and reporting errors, a related editorial calls for standardizing descriptions of preventable adverse events and harm in pediatrics. A WebM&M commentary addressed the high potential for weight-based medication errors in pediatrics and provided recommendations to help mitigate this risk.
Piccardi C, Detollenaere J, Bussche PV, et al. Int J Equity Health. 2018;17:114.
Although prior research suggests that racial and ethnic disparities in health care place certain patients at increased risk for adverse events in the inpatient setting, less is known about the effect of such disparities in the outpatient setting. This systematic review found that vulnerable populations including women and minorities are more likely to experience adverse events in primary care.