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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 107 Results
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
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.
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.
Ma C, Park SH, Shang J. Int J Nurs Stud. 2018;85:1-6.
Teamwork training interventions enhance both clinical outcomes and safety culture. This cross-sectional survey found hospital units that nurses rated as more collaborative had lower rates of both hospital-acquired pressure ulcers and falls. A PSNet Interview discusses how the nursing work environment affects patient safety.
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.
Ford EC, Evans SB. Med Phys. 2018;45:e100-e119.
Learning from adverse events is a core component of patient safety improvement. This review explores the application of this concept in radiation oncology, successful practices, and challenges for incident learning system implementation in the specialty.
Commentary
Emerging Classic
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197:1389-1395.
This commentary explores the results of a multidisciplinary discussion on the intersection of "respect" and "dignity" as requirements of safe care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, which include the need to expand the research on respect in the intensive care unit and the value of responding to failures of respect as safety incidents to design mechanisms for improvement.
Braithwaite J. BMJ. 2018;361:k2014.
In learning organizations, leadership behavior creates a supportive learning environment where concrete processes are in place to facilitate learning and encourage creativity among employees. Published in a series of quality improvement articles, this commentary suggests that a commitment to systems thinking and innovation is needed to achieve progress. Elements of a changed approach include a reduced focus on rules and policies and an enhanced effort to consider system interactions.
Edwards MT. Am J Med Qual. 2018;33:502-508.
Just culture is a movement to shift from blame for errors and instead focus on system issues in order to enhance event reporting and learning from failures. This study examined a survey about just culture in conjunction with Hospital Compare quality ratings and AHRQ's Hospital Survey on Patient Safety Culture. The vast majority of the 270 hospitals that responded to the survey reported adopting just culture. However, respondents reported no improvement in nonpunitive response to error, indicating that a culture of blame persists. The study also found no association between hospital quality ratings and just culture implementation. The author concludes that just culture is not sufficient to create a blame-free culture in hospitals. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Martin GP, Aveling E-L, Campbell A, et al. BMJ Qual Saf. 2018;27:710-717.
A work environment in which all team members feel comfortable speaking up about safety concerns is a key aspect of positive safety culture. Although formal mechanisms exist within health care institutions for raising safety issues, little is known about how such channels promote or discourage employees from speaking up. Researchers conducted interviews with 165 frontline staff and senior leaders working at three academic hospitals in two countries. They found that leaders viewed formal systems for raising concerns favorably, but other respondents felt uneasy reporting concerns through these channels. Such apprehension occurred especially if the concern was based on a general feeling that something might be wrong rather than hard evidence—what the authors refer to as "soft" intelligence. A PSNet perspective discussed how to change safety culture.
Joint Commission Resources. Oak Brook, IL: Joint Commission; 2017. ISBN: 9781599409474.
This collection of articles and case studies covers how health care organizations are working to establish and sustain a safety culture. The material includes discussions on the role of leadership, professionalism, and high reliability in improving work environments to support safety.
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.
Liberati EG, Peerally MF, Dixon-Woods M. Int J Qual Health Care. 2018;30:39-43.
The field of patient safety has long looked to high reliability organizations like aviation or nuclear power for solutions, but it is unclear how well such approaches translate to health care settings. In this study, researchers asked clinicians to identify safety hazards from their own work and then propose solutions. After applying a systems thinking framework to clinicians' solution ideas, they found that most of the clinician-generated safety approaches would be considered ineffective by high reliability standards. The authors suggest that industrial frameworks are an imperfect match for health care settings and should be used with caution. A recent PSNet interview with the study's senior author, Mary Dixon-Woods, discusses the sociology of health care versus other industries.
Campione J, Famolaro T. Jt Comm J Qual Patient Saf. 2018;44:23-32.
Measuring hospital safety culture is considered a best practice supported by both the Agency for Healthcare Research and Quality (AHRQ) and the Leapfrog Group. Although the data linking positive safety culture to patient outcomes is inconclusive, establishing a strong culture of safety is considered essential to patient safety. Researchers analyzed AHRQ Survey on Patient Safety Culture data submitted by 536 hospitals from 2007 through 2014 and identified 6 large (> 400 beds) hospitals demonstrating significant improvement over time. They then conducted interviews with quality leaders from those institutions. Qualitative analysis of interview transcripts revealed common best practices across those hospitals, including systematic safety culture measurement, widespread communication of results, both leadership and frontline engagement in improvement efforts, and implementation of patient safety initiatives. A PSNet perspective discussed how to improve safety culture.
Sexton B, Adair KC, Leonard MW, et al. BMJ Qual Saf. 2018;27:261-270.
Achieving an optimal culture of safety is a central component of patient safety. Prior research supports that higher levels of employee engagement are correlated with improved perceptions of safety culture and that higher rates of burnout are associated with more negative perceptions of safety culture. Leadership WalkRounds has been touted as an intervention to improve safety culture, although the evidence for its efficacy has been mixed. In a more recent study, clinical units that received feedback from walkrounds had lower rates of burnout and more positive perceptions of safety culture. In this cross-sectional survey study, researchers analyzed the relationship between receiving feedback on the actions resulting from walkrounds and health care employees' perceptions of safety culture, engagement, burnout, and work–life balance across 829 settings. Work environments in which walkrounds were conducted with feedback had higher safety culture and employee engagement scores. A past PSNet interview and Annual Perspective discussed the relationship between burnout and patient safety.
Dykes PC, Rozenblum R, Dalal AK, et al. Crit Care Med. 2017;45.
Establishing a strong safety culture may lead to a reduction in adverse events. Many health care institutions are focused on improving multiple aspects of culture including teamwork, communication, and patient engagement to mitigate harm. In this prospective study, researchers sought to understand the impact of a multicomponent intervention involving structured team communication as well as patient engagement tools and training on patient safety in the intensive care unit. They included 1030 admissions in the baseline period and 1075 in the intervention period. The rate of adverse events decreased by almost 30%, from 59.0 per 1000 patient days in the baseline period to 41.9 per 1000 patient days during the intervention period. Patient and care partner satisfaction improved as well. A past PSNet perspective discussed the relationship between patient engagement and patient safety.
Dekker S. Boca Raton, FL: CRC Press; 2017. ISBN: 9781472475756.
Although early efforts in the patient safety movement focused on shifting the blame for errors from individuals to system-failures, more recently the pendulum has swung slightly back to try and balance a "no blame" culture with appropriate personal accountability. This tension was notably described early on in the context of resident training programs. Dr. Dekker's book addresses the traditional criminalization of mistakes and draws from several high-risk industries to illustrate how a just culture is a more effective strategy to learn from and prevent error. He argues that a just culture in health care is critical to creating a safety culture. The third edition offers new content related to restorative justice and explores the reasons why individuals break rules.
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.
Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.
Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.