Skip to main content

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 69 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.
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.
Ratwani RM, Savage E, Will A, et al. Health Aff (Millwood). 2018;37:1752-1759.
Although health information technology has been shown to improve patient safety, problems with implementation and user interface design persist. Unintended consequences associated with the use of electronic health record (EHR) and computerized provider order entry (CPOE) systems remain a safety concern. Pediatric patients may be particularly vulnerable to medication errors associated with EHR usability. Researchers examined 9000 safety event reports over a 5-year period from 3 pediatric health care facilities and found that 5079 events were related to the EHR and medication. Of these, 3243 identified EHR usability as contributing to the event, 609 of which reached the patient. Incorrect dosing was the most common medication error detected across the three facilities. A previous WebM&M commentary highlighted the unintended consequences of CPOE.
Powers EM, Shiffman RN, Melnick ER, et al. J Am Med Inform Assoc. 2018;25:1556-1566.
Although hard-stop alerts can improve safety, they have been shown to result in unintended consequences such as delays in care. This systematic review suggests that while implementing hard stops can lead to improved health and process outcomes, end-user involvement is essential to inform design and appropriate workflow integration.
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.

Ibrahim M; Gyuchan S; Jun GT; Robinson S. Safety Sci. 2018;106:104-120.

This literature review examined the application of system dynamics, a simulation method that incorporates qualitative and quantitative data to characterize and predict how complex systems will perform over time, to patient safety. The authors applied a human factors framework to this literature and identified several influences on safety, including supervision, external factors, and organizational culture. The authors conclude that the field of system dynamics can be applied to health care in order to improve patient safety.
Simsekler MCE, Ward JR, Clarkson J. Ergonomics. 2018;61:1046-1064.
In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.
Joseph A, Bayramzadeh S, Zamani Z, et al. HERD. 2018;11:137-150.
Elements of the work environment can affect the safety of health care delivery. This literature review summarizes research to inform architectural and interior design improvements for operating rooms that support safety. The discussion highlights environmental themes associated with layout, acoustics, and lighting that can affect teamwork, processes, and communication in the operating room.
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Implement Sci. 2018;13:50.
Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Freund Y, Goulet H, Leblanc J, et al. JAMA Intern Med. 2018;178:812-819.
In emergency departments (EDs), high medical acuity, incomplete information, and productivity pressures can contribute to preventable adverse events and near misses. Systems solutions have improved medication safety and team communication in EDs, but few interventions have meaningfully affected diagnostic and treatment errors. Investigators conducted a randomized controlled trial to evaluate the impact of ED physicians' cross-checking their diagnostic and treatment plans with another physician. Compared with standard care, patients whose physicians performed cross-checking were 40% less likely to experience a preventable adverse event or near miss. This study's design, large sample size, and ascertainment of patient-centered outcomes were particularly robust. A past WebM&M commentary and PSNet perspective examined other initiatives to improve emergency department safety.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Tolley CL, Slight SP, Husband AK, et al. Am J Health Syst Pharm. 2018;75:239-246.
This systematic review of clinical decision support for safe medication use found that such systems are incompletely implemented and lack standardization and integration of patient-specific factors. The authors suggest that reducing alert fatigue and employing human factors principles would enhance decision support effectiveness.
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.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Haynes AB, Edmondson L, Lipsitz SR, et al. Ann Surg. 2017;266:923-929.
Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
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.
Carayon P, ed. Boca Raton, FL: CRC Press; 2017. ISBN: 9781439830338
Human factors principles are widely applied in high-risk industries to promote safety and are increasingly adapted by health care organizations to improve patient safety. This book provides an in-depth analysis of the intersection of design and process with the human element of health care to underscore their effects on patient safety and introduce strategies for improvement. The authors cover a wide range of health care topics including medical technology and telemedicine. A past PSNet perspective discussed the application of human factors engineering concepts.
de Jager E, McKenna C, Bartlett L, et al. World J Surg. 2016;40:1842-1858.
The World Health Organization surgical safety checklist garnered a great deal of attention after initial studies showed remarkable reductions in postoperative complication rates. However, subsequent studies failed to reproduce these results, engendering controversy about the true effectiveness of checklists in real-world settings. This systematic review of 25 studies of the surgical safety checklist found that complication rates decreased with checklist usage in resource-poor settings, but the checklist did not appear to be effective in developed nations. The authors also noted that the reported effect of the checklist was incongruous—in several studies, postoperative complications did not decrease, but postoperative mortality improved, raising questions about what mechanism helped the checklist achieve its effect. These concerns, along with methodological problems in many of the included studies, led the authors to postulate that the observed improvements seen in some studies may have been due to temporal changes or other interventions rather than the checklist itself.
Network WG for the CHECKLIST-ICUI and the BR in IC, Cavalcanti AB, Bozza FA, et al. JAMA. 2016;315:1480-90.
Checklists have contributed to some of the most effective patient safety interventions to date, including the landmark Keystone ICU program that nearly eliminated catheter–associated bloodstream infections and the surgical safety checklist that reduced mortality. More recently, checklists have failed to yield improvements in some settings, highlighting that successful programs rely on many external and internal factors beyond checklists. This randomized clinical trial studied the effect of introducing a daily checklist, goal setting, and clinician prompting in intensive care units in Brazil. This robust bundled intervention did not reduce in-hospital mortality. The intervention group showed some improvements in a few process measures, such as use of low tidal volumes, central venous catheters, and urinary catheters, but there was no difference in secondary clinical outcomes. This study adds to the current controversy over the efficacy of checklists for improving patient safety outcomes.