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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 32 Results
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. PLoS One. 2018;13:e0193510.
Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.
Ravn-Nielsen LV, Duckert M-L, Lund ML, et al. JAMA Intern Med. 2018;178:375-382.
Preventable harm is common during and after hospital discharge. Pharmacist-delivered medication reconciliation has been proposed as a strategy to reduce adverse medication events and readmissions. Investigators conducted a three-arm randomized controlled trial comparing the effect of pharmacist-delivered medication reviews, motivational interviews, and postdischarge follow-up with nursing homes, primary care providers, and pharmacies (extended intervention); simple inpatient medication reconciliation (basic intervention); and usual care (no intervention) on outcomes for medically complex patients. The extended intervention reduced hospital readmissions and emergency department visits within 180 days of discharge while the basic intervention did not. This trial was large, robustly conducted, and demonstrated a durable improvement in safety for patients at increased readmission risk. A previous Annual Perspective explored tools for safer transitions of care.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.
Johnston M, Arora S, King D, et al. Surgery. 2014;155:989-94.
This interview study examined escalation of care, the process by which a patient's deteriorating clinical status is recognized and acted upon, among surgical patients. Attending surgeons, trainees, intensivists, and rapid response team members believe that protocols for escalation of care lack clarity and that there is a dearth of supervision from senior clinicians. Similar to studies of handoffs, direct conversation—either in person or via mobile phone—was deemed preferable to hospital paging systems. Participants identified communication training, explicit and clear protocols, and increased supervision as key to improving the care of deteriorating surgical patients. Accompanying editorials highlight the importance of communication and the need for a safety culture that supports multidisciplinary teams.
Kripalani S, Roumie CL, Dalal AK, et al. Ann Intern Med. 2012;157:1-10.
Hospital discharge remains a particularly vulnerable time for adverse drug events, despite the use of medication reconciliation and other strategies to prevent medication errors at discharge. Previously, pharmacist involvement has also been shown to be beneficial in reducing medication errors, and even led to decreased readmissions in at least one study. However, in this randomized, controlled trial, approximately 50% of adult patients who received a robust pharmacist-driven intervention still experienced a clinically important medication error within one month following discharge for an episode of acute coronary syndrome or acute decompensated heart failure. The four-component intervention included pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. A case of a preventable readmission due to a medication error is discussed in this AHRQ WebM&M commentary.
Jones DA, DeVita MA, Bellomo R. N Engl J Med. 2011;365:139-46.
Delays in clinical deterioration recognition and failures to rescue lead to serious adverse events. Rapid response systems (RRS) have been implemented with the aim of improving the identification and management of clinically worsening hospital ward patients. Although early studies reviewing RRS showed improvements in clinical outcomes, subsequent results have not shown consistent benefit. This review describes RRS, including controversies surrounding them, potential benefits and limitations, as well as strategies to implement them successfully. An AHRQ WebM&M perspective discusses lessons from early experiences with RRS.
Scott SD, Hirschinger LE, Cox KR, et al. Jt Comm J Qual Saf. 2010;36:233-240.
Rapid response systems (RRS) continue to penetrate hospitals nationally as a method to rescue patients experiencing imminent clinical deterioration. This study takes the same model and describes the context for and development of an innovative RRS to care for the second victim—a health care provider involved in an unanticipated adverse event, medical error, or patient-related injury. The authors surveyed faculty and staff at their institution and found that 39% were familiar with the term second victim and 30% reported personal problems in the past 12 months resulting from their involvement in a patient safety event. More than 80% of respondents expressed a desire for internal rather than external support when needing assistance. Early learnings from a second victim RRS are described, including training of "clinician lifeguards" and monitoring of the interventions. A past AHRQ WebM&M commentary explored how providers recover from their involvement in medical errors.
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.
Chan PS, Jain R, Nallmothu BK, et al. Arch Intern Med. 2010;170:18-26.
Rapid response systems are one of the most widely deployed patient safety interventions in hospitals. Most hospitals maintain some form of RRS, due in part to a 2008 National Patient Safety Goal that required hospitals to maintain a dedicated system for urgent assistance for clinically unstable patients. However, this systematic review and meta-analysis found no definitive evidence that the teams improved in-hospital mortality in adult or pediatric patients. Although RRS usage was associated with decreased cardiac arrest rates on general wards, overall mortality rates did not improve, and the review noted significant problems with the methodological quality of many RRS studies. RRS have proven to be a very popular intervention among nursing staff, and this factor alone may justify implementation of some form of RRS.
Cohen V, Jellinek SP, Hatch A, et al. Am J Health Syst Pharm. 2009;66:1353-1361.
Prevention of medication errors in emergency departments is a growing focus of safety efforts, due in part to a National Patient Safety Goal targeting medication errors. Clinical pharmacists effectively prevent medication errors in the inpatient setting, but their role in the emergency department is less studied. This systematic review of 17 published studies characterizes roles played by emergency pharmacists, including medication reconciliation, error prevention, and a variety of other duties. Another study (not included in this review) found a significant reduction in medication errors after assigning pharmacists to review medication orders in the emergency department. 
Chan PS, Khalid A, Longmore LS, et al. JAMA. 2008;300:2506-13.
A rapid response team consisting of ICU nurses and respiratory therapists with physician backup failed to affect mortality or cardiopulmonary arrest rates at a tertiary care community hospital. While several studies and reviews have attempted to address the effectiveness of rapid response systems, this study's conclusions are strengthened by sophisticated statistical analysis, as well as the finding that the rapid response team was not underutilized (a criticism of prior negative trials). These findings are contrary to those reported in a recent trial conducted in a children's hospital. Despite already being widely implemented, rapid response systems are likely to remain controversial.
Pronovost PJ, Berenholtz SM, Goeschel C, et al. J Crit Care. 2008;23:207-212.
The Keystone ICU project is a landmark achievement in patient safety. This project, funded by AHRQ, represented a collaboration between patient safety experts at Johns Hopkins University and the Michigan Hospital Association to improve patient safety in 99 intensive care units (ICUs). This article discusses implementation of the comprehensive unit-based safety program, which was the cornerstone of the project, and provides detailed information on the organizational change model used as well as the interventions that were implemented. The remarkable successes achieved by this project include near-elimination of catheter-related bloodstream infections and a significant improvement in the safety culture in participating ICUs. The project's principal investigator, Dr. Peter Pronovost, was interviewed by AHRQ WebM&M near the project's conclusion in 2005.
Lindenauer PK, Rothberg MB, Pekow PS, et al. New Engl J Med. 2007;357:2589-2600.
Hospitalists are the fastest-growing medical specialty in the US, but their effect on quality of inpatient care has not been comprehensively assessed. This large observational study compared outcomes of patients cared for by hospitalists, general internists, and primary care physicians. Inpatient mortality and readmission rates were similar across all three groups of patients, and while hospitalists' patients had a slightly shorter length of stay, costs of care were also similar across groups. The study also did not find a relationship between case volume and outcomes. 
Ranji SR, Auerbach AD, Hurd CJ, et al. J Hosp Med. 2007;2:422-432.
Rapid response systems (RSS) have been widely endorsed and implemented, but controversy remains regarding their benefit on clinical outcomes. This systematic review of 13 published studies found no overall benefit of RRS on inpatient mortality, cardiac arrests, or unanticipated intensive care unit transfer. As noted in a prior commentary, most published studies had significant methodologic problems that limited their generalizability. While some more recent single-center studies of RRS have achieved impressive results, the authors of this review call for further research into the effectiveness of specific RRS models and the patient populations that may benefit most from RRS availability.
Sharek PJ, Parast LM, Leong K, et al. JAMA. 2007;298:2267-74.
Despite existing controversy over their reported benefits, implementation and endorsement of rapid response teams (RRTs) remains widespread. This study demonstrated significant reductions in hospital-wide mortality and code rates after implementation of an RRT in a children's hospital. The team consisted of a critical care physician, nurse, respiratory therapist, and nursing supervisor. Generalizing the results from positive RRT outcome studies is often limited by methodological issues, such as defining clear triggers for activation and determining optimal composition of the RRT. A past study also demonstrated clinical outcome benefits, but used a physician assistant–led RRT. An accompanying editorial [link below] discusses these issues and the implications of this study for RRTs in pediatric inpatient care.
Wachter RM, Pronovost PJ. Jt Comm J Qual Patient Saf. 2006;32:621-7.
In June 2006, the Institute for Healthcare Improvement (IHI) announced that hospitals participating in their 100,000 Lives Campaign saved an estimated 122,300 lives. In an invited commentary, Drs. Robert Wachter and Peter Pronovost critically analyze the campaign, the interventions promoted, and the "lives saved" estimates. While applauding IHI's remarkable efforts in stimulating the system to improve quality and safety, the authors raise concerns about the evidence base behind the recommended interventions (particularly rapid response teams) and the methodology underlying the lives saved estimate. Even as they critique some of the science, they suggest that the campaign's success in engaging so many (approximately 3,000) hospitals may hold lessons for other organizations seeking to promote improved health care. IHI President Dr. Don Berwick and colleagues respond to the commentary (available via the link below), welcoming the critical appraisal while defending both the interventions and the methods used in reporting the campaign's outcomes. Wachter and Pronovost offer further comments in response.
Coleman EA, Parry C, Chalmers S, et al. Arch Intern Med. 2006;166:1822-8.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
Winters BD, Pham JC, Pronovost PJ. JAMA. 2006;296.
Rapid response teams (RRTs) have been widely advocated as a means of averting adverse clinical outcomes for inpatients, by intervening and treating patients before they become critically ill. However, this commentary finds that the published evidence concerning RRTs is generally of poor methodological quality and does not conclusively demonstrate any benefits for patients. The authors conclude that RRTs are a potentially useful intervention but not one worthy of wider implementation until more definitive evidence is available.
Kaboli PJ, Hoth AB, McClimon BJ, et al. Arch Intern Med. 2006;166:955-64.
This systematic review evaluated 36 studies that encompassed pharmacy participation in patient rounds and medication reconciliation efforts as well as drug-specific pharmacist services. The authors detail the individual and collective findings, which include reductions in adverse drug events or errors in more than half the trials with improvements in medication adherence, knowledge, and appropriateness in a similar proportion. None of the studies demonstrated a worse overall outcome, and only one suggested increased health care utilization. The authors outline the needs for future investigation around roles for clinical pharmacists, clinical areas and patients most likely to benefit from their services, and better models to determine cost effectiveness.
Schnipper JL, Kirwin JL, Cotugno MC, et al. Arch Intern Med. 2006;166:565-571.
This study found a lower rate of preventable adverse drug events (ADEs) for patients who received medication review, counseling, and telephone follow-up from a hospital pharmacist. Investigators randomized nearly 100 medical patients to receive the pharmacy intervention and found that only 1% of those patients experienced a preventable ADE (11% in the control group). The overall rate of ADEs was similar in both groups. Additional findings included observation of unexplained discrepancies between preadmission and discharge medication regimens in nearly half the patients. This finding supports national interests in medication reconciliation. A past study suggested similar benefits of pharmacy participation in daily rounds in an intensive care unit.