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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 145 Results
Levy AG, Scherer AM, Zikmund-Fisher BJ, et al. JAMA Netw Open. 2018;1:e185293.
Diagnostic errors and delays may occur when patients fail to disclose medically relevant information. This study analyzed online survey responses from 4510 patients and found that about 70% reported not disclosing information. Disagreement with a clinician's recommendation or failure to understand a clinician's instructions were common. Patients most often did not disclose because they feared judgment from the clinician or felt embarrassed.
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.
Reeve E, Wolff JL, Skehan M, et al. JAMA Intern Med. 2018;178:1673-1680.
Deprescribing or stopping unnecessary medications is an important strategy for reducing medication-related harm in older adults. A group of 1981 Medicare beneficiaries reported broad support (92%) for stopping at least one of their medications if their clinician determined it was safe. A WebM&M commentary provides in-depth recommendations to achieve safe prescribing in older patients.
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Nickel WK, Weinberger SE, Guze PA, et al. Ann Intern Med. 2018;169:796-799.
Patient and family engagement can enhance both individual safety and organizational improvement efforts. This position paper advocates for patients and families to be active partners in all aspects of their care, treated with respect and dignity, engaged in improving health care systems, and directly involved in education of health care professionals. The piece also provides strategies to employ these recommendations in the daily practice.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
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.
Mann S, Hollier LM, McKay K, et al. New Engl J Med. 2018;379:1689-1691.
Maternal morbidity has received increasing attention as a patient safety issue. This commentary recommends four strategies for improving obstetrics safety: focusing on prevention of complications, using multidisciplinary huddles to enhance communication, employing simulation as a teamwork training model, and developing partnerships between hospitals to ensure the best care is available.
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.
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.
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.
Schiff GD, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
Fønhus MS, Dalsbø TK, Johansen M, et al. Cochrane Database Syst Rev. 2018;9:CD012472.
Engaging patients in their care can enhance safety, quality, and satisfaction. The Joint Commission and Centers for Medicare and Medicaid Services both call for health care organizations to encourage patient engagement in their care. This review and meta-analysis assessed which patient engagement strategies improve clinician adherence to recommended clinical practice. Two strategies had moderate impact: enhancing the information elicited from patients and educating patients about best clinical practice. Patient decision aids did not affect clinician performance, and the authors were unable to determine how interventions impacted health outcomes. A PSNet perspective explored novel avenues for patient engagement that leverage health information technology.
Ramani S, Könings KD, Mann K, et al. Acad Med. 2018;93:1348-1358.
Constructive feedback is a pillar of strong safety culture. Through resident and attending physicians focus groups at a single institution, investigators found that cultural emphasis on politeness and excellence hindered all parties' ability to provide honest feedback. The authors advocate for transitioning to a culture of growth, which would shift their institution toward a more just culture.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
Redmond P, Grimes TC, McDonnell R, et al. Cochrane Database Syst Rev. 2018;8:CD010791.
This systematic review identified 25 randomized controlled trials of methods to improve medication reconciliation at the time of hospital discharge, most of which involved a pharmacist-mediated intervention. Overall, there was no clear evidence that medication reconciliation interventions reduced either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in implementing effective medication reconciliation programs in real-world settings.
Lane MA, Newman BM, Taylor MZ, et al. J Patient Saf. 2018;14:e56-e60.
The second victim phenomenon refers to the emotional and psychological toll experienced by clinicians who are involved in an adverse event. Peer support has been shown to benefit second victims, especially if initiated promptly after an adverse event. This study describes the implementation and early effects of a second victim peer support program at an academic medical center, which involved training physicians and advanced practice providers as peer supporters. A WebM&M interview with Dr. Albert Wu discussed ways that organizations can support second victims.
Shahid S, Thomas S. Saf Health. 2018;4.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic used to structure information sharing to avoid communication failures during handoffs. This review examines the challenges and benefits associated with SBAR use and provides a comparative assessment with other standardized communication tools in the field.