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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 65 Results
Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.
Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
Sloane DM, Smith HL, McHugh MD, et al. Med Care. 2018;56:1001-1008.
Prior research suggests that improved nursing resources may be associated with decreased mortality and adverse events. However, less is known about how changes to nursing resources in the inpatient setting may affect quality and safety over time. In this study involving 737 hospitals and survey data from nurses obtained in 2006 and 2016, researchers found that after adjusting for numerous factors, better nursing resources in terms of work environment, staffing, and education was associated with improvement in quality and patient safety outcomes. A PSNet perspective discussed the impact of nursing resources on patient 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.
Tubbs-Cooley HL, Mara CA, Carle AC, et al. JAMA Pediatr. 2019;173:44-51.
Excessive nursing workload is a known safety issue. This study examined whether nurse workload in the neonatal intensive care unit affected the quality of nursing care. Investigators measured workload using patient–nurse ratios, taking into account patient acuity, and a convenience sample of nurses also reported their perceived workload. Participating nurses were asked to report the care they provided, and missed care was defined as self-reported failure to provide any of 11 prespecified essential elements of nursing care. The authors identified a consistent association between perceived workload and missed care, suggesting that nurses' own assessments of their workload should be a safety consideration. A PSNet perspective explores how missed nursing care may explain the association between low nurse staffing levels and increased mortality in hospital patients.
Schwartz SP, Adair KC, Bae J, et al. BMJ Qual Saf. 2019;28:142-150.
Burnout is a highly prevalent patient safety issue. This survey study examined work–life balance and burnout. Researchers validated a novel survey measure for work–life balance by asking participants to report behaviors like skipping meals and working without breaks. Residents, fellows, and attending physicians reported the lowest work–life balance, and psychologists, nutritionists, and environmental services workers reported the highest work–life balance. Time of day and shift length also influenced work–life balance: day shift had better scores compared to night shift, and shorter shifts had better scores than longer shifts. The work–life balance score also clustered by the work setting: individuals with different roles within a given setting (such as the intensive care unit, the emergency department, or the clinical laboratory) had more similar work–life balance. Those with higher work–life balance reported better safety culture and less burnout. The authors suggest that burnout interventions target work settings rather than individuals, because work–life balance seems to function as a shared experience within health care settings.
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.
Mitchell BG, Gardner A, Stone PW, et al. Jt Comm J Qual Patient Saf. 2018;44:613-622.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. In this systematic review, researchers found that increased hospital staffing was generally associated with decreased rates of health care–associated infections.
Carthon MB, Hatfield L, Plover C, et al. J Nurs Care Qual. 2019;34:40-46.
This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Desai SV, Asch DA, Bellini LM, et al. New England Journal of Medicine. 2018;378.
Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Moran D, Wu AW, Connors C, et al. J Patient Saf. 2020;16:e250-e254.
Medical errors and adverse events can have a devastating psychological impact on the providers involved, often referred to as second victims. Increasingly, health care institutions are implementing programs designed to provide emotional support to team members who experience emotional distress as a result of adverse events. This study provides an economic cost–benefit evaluation of the Resiliency In Stressful Events (RISE) program at Johns Hopkins Hospital. Investigators estimate a savings of $22,576.05 per nurse who used the RISE program and suggest that the hospital might save as much as $1.81 million annually as a result of RISE. These findings are consistent with a previous study, which demonstrated the positive impact of an emotional support program on work-related outcomes such as turnover intentions and absenteeism. In a past PSNet perspective, Susan Scott discussed the second victim phenomenon and its impact on health care providers.
Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374:713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Govindarajan A, Urbach DR, Kumar M, et al. N Engl J Med. 2015;373:845-53.
The link between lack of sleep and subsequent medical errors served as an impetus for physician duty-hours reform. In trainee physicians, sleep loss is associated with attentional failures, but little is known about the relationship between attending physician performance and sleep loss. This retrospective cohort study examined outcomes of elective surgical procedures among attending surgeons who had worked after midnight on the previous night versus those who had not. The investigators found no differences in mortality, complications, or readmissions between procedures performed by surgeons with sleep loss compared to those without sleep loss, mirroring results of an earlier simulation study. This may be due to greater technical skill among attending surgeons, or the ability to cancel or postpone elective procedures as needed at times of fatigue. This study included many institutions, physicians, and procedure types, suggesting that short-term sleep deprivation might not be a high-yield safety target for attending surgeons.
Elmore JG, Longton GM, Carney PA, et al. JAMA. 2015;313:1122-32.
Microscopic review of biopsy tissue is considered the gold standard for diagnosis of cancer and other diseases, but prior research has shown a small yet consistent rate of errors in cancer diagnosis that is attributable to misinterpretation of biopsy specimens. This study sought to quantify error rates in breast cancer diagnosis by having a broad sample of pathologists review a standardized set of biopsies whose diagnoses had been established by expert clinicians. Although biopsies with cancer were diagnosed very accurately, specimens with atypia (abnormal tissue that may be pre-cancerous) had substantial variability, with pathologists tending to overdiagnose these specimens (i.e., ascribe a diagnosis of cancer or pre-cancerous lesions when the correct diagnosis was benign). The authors caution that the specimens used in this study were intentionally chosen to be relatively difficult to interpret, and this may have resulted in overestimating the error rate. A related editorial notes that while the overall rate of diagnostic error in this study was low, misdiagnosis of atypia does have important prognostic and treatment significance for women, and therefore pathologists should systematically consult with colleagues in difficult cases, and more advanced molecular diagnostic methods should be applied in order to reduce subjectivity in biopsy interpretation.
Rajaram R, Chung JW, Jones AT, et al. JAMA. 2014;312:2374-84.
This observational study analyzed surgical outcomes before and after 2011 ACGME duty hours reform using data from the American College of Surgeons National Surgical Quality Improvement Program. Researchers applied difference-in-differences analysis, which can account for some of the uncertainty of nonrandomized data, a common concern in patient safety research. They assessed changes in surgical mortality and complication rates before and after implementation of duty hours restrictions in teaching hospitals. The authors compared this difference with mortality and complication rates during the same time period in nonteaching hospitals. Any variation between teaching and nonteaching sites could be attributed to the effects of duty hours, since the authors accounted for case mix and comorbidities. No differences in patient outcomes were observed, adding to the evidence that duty hours restrictions do not improve patient outcomes. Researchers also found no change in trainee examination scores, despite concerns that duty hours adversely impact trainee education. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.
Patel MS, Volpp KG, Small DS, et al. JAMA. 2014;312:2364-73.
This observational study sought to determine whether the ACGME 2011 duty hour reforms led to changes in 30-day mortality or readmissions for several medical diagnoses—acute myocardial infarction, stroke, acute gastrointestinal bleed, or congestive heart failure—and for general, orthopedic, or vascular surgery. The authors examined how hospital teaching status, which they defined using resident-to-bed ratio, affected outcomes for these conditions. This measure provides insight into the intensity of teaching at a given institution rather than defining each hospital as teaching versus nonteaching. During the study time period, although readmissions and mortality both declined overall, this decrease did not differ based on teaching status, suggesting that the improvement in readmissions and 30-day mortality is not attributable to duty hour reform. These results are consistent with prior work following the 2003 duty hour reforms which has failed to demonstrate benefit to patient outcomes from costly duty hour reforms. An editorial discussing this work and a companion study urge flexibility in duty hours for physicians in training.
Dai H, Milkman KL, Hofmann DA, et al. J Appl Psychol. 2015;100:846-62.
This large observational study demonstrated that hand hygiene compliance rates decrease over the course of a normal work shift. During the first hour of work, average compliance rates were approximately 43%. This dropped to 35% for the last hour of a 12-hour shift. In addition, more intense work shifts were associated with even bigger hand hygiene compliance drop-offs. The authors extrapolate these results to estimate that this compliance decrement could produce an additional 600,000 infections per year in the United States, resulting in up to 35,000 unnecessary deaths and $12.5 billion in excess costs. More time off between shifts led to better compliance rates during a subsequent shift. In this sample, 65% of the caregivers were nurses, and only 4% were physicians. Longer nursing shifts have previously been linked to other patient safety hazards. A prior AHRQ WebM&M commentary discussed challenges related to nursing staffing.
Ahmed N, Devitt KS, Keshet I, et al. Ann Surg. 2014;259:1041-53.
The 2011 duty hour regulations for resident physicians were intended to improve patient safety by reducing resident fatigue. Examining the effects of duty-hours reform on surgical trainees, this systematic review concluded that there were no improvements in patient outcomes. Both perceived education and performance on certification exams have declined following reform, and more frequent handoffs have led to safety concerns. Even though some improvements in residents' quality of life were observed after the first duty-hours reform, the subsequent limitation of 16-hour shifts has not enhanced well-being. The authors express concern about current surgery residency training and urge caution prior to reforming graduate medical education further. A previous AHRQ WebM&M perspective explored the impact of duty hours on patient safety.