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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 40 Results
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.
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.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Ward ME, De Brún A, Beirne D, et al. Int J Environ Res Public Health. 2018;15:E1182.
Change initiatives require broad-based collective design strategies to ensure the range of needs are addressed. This commentary explains how one hospital group used codesign methods to engage leadership in a teamwork and culture improvement project. The authors describe specific tools and tactics used to implement the work and summarize the value of the approach for other health care organizations.
Welp A, Meier LL, Manser T. Crit Care. 2016;20:110.
Emotional exhaustion is a component of burnout—a critical patient safety issue. Teamwork promotes resilience and thus may protect against burnout and promote patient safety. However, it is unclear how teamwork, burnout, and patient safety interact in a safety culture. This prospective study of critical care interprofessional teams found that clinicians' emotional exhaustion affects teamwork, which leads to worsening clinician reports of patient safety. The authors suggest addressing clinicians' emotional exhaustion prior to team training in order to best augment patient safety in the intensive care unit. A PSNet interview discusses strategies to enhance clinicians' emotional resilience.
Berry JC, Davis JT, Bartman T, et al. J Patient Saf. 2020;16:130-136.
A culture of safety is a fundamental component of patient safety. Several validated survey tools are available to measure hospital safety and teamwork climates, including the AHRQ Surveys on Patient Safety Culture and the Safety Attitudes Questionnaire (SAQ). Improvements in SAQ scores have been previously linked to reductions in specific safety outcomes, such as maternal and fetal adverse events in an obstetric ward. This study explored SAQ results and outcomes across all inpatient and outpatient care units in a large academic health system. Beginning in 2009, Nationwide Children's Hospital in Ohio introduced a comprehensive patient safety and high reliability program that included numerous quality improvement activities and extensive training in error prevention for each of their approximately 10,000 employees. Over the course of 4 years, SAQ scores improved while all-hospital harm, serious safety events, and severity-adjusted hospital mortality all decreased significantly. A prior WebM&M interview with J. Bryan Sexton, the primary author of the SAQ instrument, discussed the relationship between culture and safety.
Riskin A, Erez A, Foulk TA, et al. Pediatrics. 2015;136:487-95.
Disruptive physician behavior is a recognized patient safety problem. Fear of confrontation with a disruptive individual may inhibit speaking up about potential errors and worsen safety culture and teamwork. In this simulation study, neonatal intensive care unit teams were exposed to either rude or neutral comments from an observer during their assigned simulated task. Compared to teams receiving neutral comments, those who were exposed to rudeness performed worse. This study complements prior studies which document perceived consequences of disruptive behavior by demonstrating worse simulated task performance. This work also reveals that rudeness external to a team can affect performance and suggests that a polite work culture would foster patient safety.
Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Washington, DC: National Academies Press; 2015. ISBN: 9780309377690.
The National Academy of Medicine (formerly the Institute of Medicine) launched the patient safety movement with the publication of its report To Err Is Human. The group has now released a report about diagnosis, which they describe as a blind spot in health care. Available evidence suggests that most Americans will experience a missed or delayed diagnosis in their lifetime. The committee made several recommendations to improve diagnosis, including promoting teamwork among interdisciplinary health care teams, enhancing patient engagement in the diagnostic process, implementing large-scale error reporting systems with feedback and corrective action, and improving health information technology (as recommended in prior reports). Longer-term recommendations include establishing a work system and safety culture that foster timely and accurate diagnosis, improving the medical liability system to foster learning from missed or delayed diagnoses, reforming the payment system to support better diagnosis, and increasing funding for research in diagnostic safety. The report emphasizes the need for much more effort, and far more resources, at the practice, policy, and research levels to address this pressing safety problem.
Pannick S, Davis R, Ashrafian H, et al. JAMA Intern Med. 2015;175:1288-98.
Interdisciplinary team care interventions are increasingly common on medical wards, based partly on a widespread belief that these practices will improve efficiency and patient safety. This systematic review sought to evaluate the performance of hospital-based interdisciplinary teams on patient outcomes. The majority of studies have chosen length of stay, complications, readmission, or mortality rates as their primary outcomes, but interdisciplinary teams rarely seem to affect these traditional quality measures, which may be insensitive to teamwork improvements in care delivery. The authors call for establishing more relevant outcomes to evaluate interdisciplinary team interventions. An accompanying commentary notes that this systematic review provides an opportunity to highlight the potential harms of choosing the wrong metrics to evaluate an intervention, which can undermine a program's mission.
O'Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.
Interdisciplinary teamwork is a primary driver of safety culture, and lack of teamwork has been linked to poor clinical outcomes in surgery and the emergency department. Creating high-functioning teams is challenging in inpatient medicine wards, due to numerous barriers including variability in physician and nurse schedules and communication styles. This study, which built on prior work by the same authors, sought to improve interdisciplinary teamwork at a teaching hospital by creating structured, daily rounds where the entire care team discussed patients. The intervention resulted in a significant decrease in preventable adverse events compared with historical and concurrent controls. The accompanying editorial notes that the hospital where this study was conducted had several structural features that also encouraged interdisciplinary communication (such as an electronic health record), and that structured interdisciplinary rounds could have an even larger impact at hospitals lacking such features.
Book/Report
Classic

Vincent C. West Sussex, UK: Wiley-Blackwell; 2010. ISBN: 9781405192217.  

Dr. Charles Vincent, a psychologist by training, is unquestionably one of the founders of the modern patient safety movement and continues to publish groundbreaking research in the field. This essential textbook discusses the evolution of patient safety efforts, outlines current medical error reduction strategies, and emphasizes practical examples of initiatives to improve patient safety. Dr. Vincent was interviewed for AHRQ WebM&M in 2012, and discussed his career as well as the current state of patient safety in the United Kingdom.
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.
Kim MM, Barnato AE, Angus DC, et al. Arch Intern Med. 2010;170:369-76.
Efforts to improve the care of complex patients in intensive care units (ICUs) focus on many factors, including unit-based initiatives. This retrospective study evaluated the relationship between daily multidisciplinary rounds and 30-day mortality. Investigators discovered that the presence of daily rounds was associated with lower mortality among medical ICU patients. In addition, the survival benefits observed with intensivist staffing were in part explained by the presence of multidisciplinary care models. A related commentary [see link below] discusses this study's findings and the concept of health engineering as a systems science to study how we optimize staffing and patient outcomes in the ICU.

Croskerry P, Cosby KS, Schenkel SM, Wears RL, eds. Philadelphia, PA: Lippincott Williams & Wilkins; 2009. ISBN: 9780781777278.

The pace, diversity, and scope of an emergency department (ED) create a setting particularly prone to medical error. This comprehensive textbook provides important information on developing and advancing patient safety in emergency medicine, including relevant content on the ED setting, medical errors, organizational approaches to safety, teamwork, education, and human performance. The target audience is primarily emergency physicians and administrators but likely would extend to other allied health professionals and patient safety advocates. This textbook sets a foundation for the establishment of patient safety practices within emergency medicine.
Leape L, Berwick D, Clancy C, et al. Qual Saf Health Care. 2009;18:424-8.
Although significant progress has been made in improving patient safety over the past decade, most health care organizations still experience persistent safety problems. In this commentary, leaders of several leading safety organizations endorse five principles for transforming hospitals and clinics into high reliability organizations. These include transparency in disclosing errors and quality problems, integration of care across teams and disciplines, engaging patients in safety, developing a culture of safety, and reforming medical education to focus on quality and safety. The lead author, Dr. Lucian Leape, was interviewed about his remarkable career in patient safety by AHRQ WebM&M in 2006.
Haller G, Myles PS, Taffé P, et al. BMJ. 2009;339:b3974.
The so-called July phenomenon, in which errors are supposedly more common in July due to an influx of inexperienced residents and students, has long been a source of gallows humor in hospitals. Although prior studies have reached mixed conclusions, this Australian study of anesthesia errors did find a significant increase in preventable adverse events for procedures performed by trainees during the first 4 months of the academic year. Interestingly, error rates were higher for trainees at all levels, not just first-year residents. This finding implies that underlying systems issues as well as clinical inexperience resulted in adverse events. An accompanying editorial calls for revising training models in order to provide adequate supervision and support for new trainees. A case of inadvertent hypoglycemia resulting from an intern's lack of familiarity with insulin ordering at his new hospital is discussed in an AHRQ WebM&M commentary.
Haynes AB, Weiser TG, Berry WR, et al. N Engl J Med. 2009;360:491-9.
Success in patient safety is generally measured in incremental steps rather than giant leaps, but this pioneering study certainly represents the latter. Eight hospitals with widely differing resources and patient populations were required to implement a checklist based on the World Health Organization's Safe Surgery Saves Lives guidelines. The 19-item checklist focused on three key junctures: sign in (before induction of anesthesia), timeout (immediately before skin incision), and sign out (when the patient is ready to leave the operating room). It also included specific measures to improve teamwork and reduce the risk of surgical site infection. Checklist implementation resulted in significant reductions in mortality and inpatient complications. Checklists have already proved to be a powerful intervention in improving patient safety. This study's senior author, Atul Gawande, wrote about the success of checklists in preventing central-line associated bloodstream infections in a 2007 New Yorker article.