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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 105 Results
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.
Bates DW, Singh H. Health Aff (Millwood). 2018;37:1736-1743.
The release of the Institute of Medicine's To Err Is Human in 1999 represented a seminal moment in patient safety and is considered by many to have launched the modern patient safety movement. The report highlighted the incidence of medical errors and preventable deaths in the United States and catalyzed research to identify interventions for improvement. The authors reflect on progress since its publication and suggest that while many effective interventions have been developed for addressing safety challenges such as hospital-acquired infections and medication errors, successful implementation of these solutions remains difficult, and improvement in other areas has been less consistent. In addition, new safety challenges have emerged in the last 20 years including those related to ambulatory care and diagnostic error. The authors conclude that preventable harm remains significant and advocate for enhanced use of widely available electronic data to develop improved interventions for what they foresee may be a Golden Era of swift progress in patient safety. A PSNet perspective reflected on patient safety progress in surgery. The Moore Foundation provides free access to this article.
Meisenberg BR, Grover J, Campbell C, et al. JAMA Netw Open. 2018;1:e182908.
Opioid deaths are a major public health and patient safety hazard. This multimodal, health care system-level intervention to reduce opioid overprescribing consisted of changes to the electronic health record, patient education, and provider education and oversight. Opioid prescribing decreased substantially (58%) systemwide with no discernible decrement in patient satisfaction.
Bates DW, Landman A, Levine DM. JAMA. 2018;320:1975-1976.
Mobile health care applications are increasingly being developed and marketed to patients for self-care and diagnosis, with little oversight as to their effectiveness or safety. This commentary outlines four key issues that must be addressed to improve the safety of medical applications.
Murphy DR, Meyer AN, Sittig DF, et al. BMJ Qual Saf. 2019;28:151-159.
Identifying and measuring diagnostic error remains an ongoing challenge. Trigger tools are frequently used in health care to detect adverse events. Researchers describe the Safer Dx Trigger Tools Framework as it applies to the development and implementation of electronic trigger tools that use electronic health record data to detect and measure diagnostic error. The authors suggest that by identifying possible diagnostic errors, these tools will help elucidate contributing factors and opportunities for improvement. They also suggest that, if used prospectively, such tools might enable clinicians to take preventive action. However, to design and implement these electronic trigger tools successfully, health systems will need to invest in the appropriate staff and resources. A past PSNet perspective discussed ongoing challenges associated with diagnostic error.
Scott IA, Pillans PI, Barras M, et al. Ther Adv Drug Saf. 2018;9:559-573.
The prescribing of potentially inappropriate medications is a quality and safety concern. This narrative review found that information technologies equipped with decision support tools were modestly effective in reducing inappropriate prescribing of medications, more so in the hospital than the ambulatory environment.
Weiner SG, Price CN, Atalay AJ, et al. Jt Comm J Qual Patient Saf. 2019;45:3-13.
Multidisciplinary organizational efforts are necessary to reduce inappropriate prescribing of opioids. This commentary describes the design and implementation of an opioid stewardship program that combined the use of technology, education, and clinical strategies under strong leadership guidance as a cross-disciplinary strategy to address opioid misuse.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.
Rodriguez-Gonzalez CG, Herranz-Alonso A, Escudero-Vilaplana V, et al. J Eval Clin Pract. 2019;25:28-35.
Pharmacy robots are now commonly used in hospitals for dispensing medications. Conducted at a Spanish hospital, this study found that use of pharmacy robots reduced medication dispensing errors and improved staff efficiency. The role of a pharmacy robot in a serious medication error is explored in a book that examined the effects of technological change on the health care system.
Gianfrancesco MA, Tamang S, Yazdany J, et al. JAMA Intern Med. 2018;178:1544-1547.
Machine learning, a type of computing that uses data and statistical methods to enable computers to progressively enhance their prediction or task performance over time, has been widely promoted as a tool to improve health care safety. This commentary describes the potential for machine learning to worsen socioeconomic disparities in health care. Disadvantaged populations are more likely to receive care in multiple health systems. Therefore, relevant data about their health may be missing in an individual health system's records, hindering performance of machine learning algorithms. Racial and ethnic minority patients may not be present in sufficient numbers for accurate prediction. The authors raise concern that implicit bias in the care that disadvantaged populations receive may influence algorithms, which will amplify this bias. They recommend inclusion of sociodemographic characteristics into algorithms, building and testing algorithms in diverse health care systems, and conducting follow-up testing to ensure that machine learning does not perpetuate or exacerbate health care disparities.
Zhou L; Blackley SV; Kowalski L; Doan R; Acker WW; Landman AB; Kontrient E; Mack D; Meteer M; Bates DW; Goss FR.
Clinical documentation is an essential part of patient care. However, in the electronic health record era, documentation is widely perceived to be inefficient and a significant driver of physician burnout. Speech recognition software, which directly transcribes clinicians' dictated speech, is increasingly being used in order to streamline the documentation workflow. This study examined the accuracy of speech recognition software in a sample of notes (progress notes, operative notes, and discharge summaries) produced by 144 clinicians of multiple disciplines in 2 health systems. Transcripts produced by speech recognition software had 7.4 errors per 100 transcribed words, with many of these errors being potentially clinically significant. Although review by a professional medical transcriptionist corrected most of these errors, about 1 in 300 words remained incorrect even in the final physician-signed note. This study corroborates prior research that found potentially significant error rates in software-transcribed emergency medicine and radiology notes. A WebM&M commentary discussed an adverse event that occurred due to a transcription error in a radiology study report.

Loh E. BMJ Leader. 2018;2(2):59-63.

Artificial intelligence (AI) can improve diagnostic accuracy. Despite early enthusiasm for the utility of AI at the front line, some have raised concerns associated with legal liabilities and ethical issues. This review discusses these considerations and suggests approaches that leaders and clinicians should embrace to prepare for future integration of AI systems in practice.
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.
Vaughn VM, Linder JA. BMJ Qual Saf. 2018;27:583-586.
Despite the benefits of health information technology, such systems can have detrimental effects on clinician decision-making. This commentary discusses how electronic health record design can contribute to inappropriate test ordering. The author recommends that influences such as heuristics and social norms be considered when developing electronic health record systems to improve care.
van der Veen W, van den Bemt PMLA, Wouters H, et al. J Am Med Inform Assoc. 2018;25:385-392.
Workarounds occur frequently in health care and can compromise patient safety. In this prospective study, researchers observed 5793 medication administrations to 1230 inpatients in Dutch hospitals using barcode-assisted medication administration (BCMA). Workarounds occurred in about two-thirds of medication administrations. They found a significant association between workarounds and medication administration errors. The most frequently observed medication administration errors included omissions, administration of drugs not actually ordered, and dosing errors. The authors suggest that BMCA merits further evaluation to ensure that implementation of this technology promotes safety effectively. A past PSNet perspective discussed workarounds on the front line of health care.
Kim BY, Sharafoddini A, Tran N, et al. JMIR Mhealth Uhealth. 2018;6:e74.
Patients are powerful allies in improving medication safety. This study found that available mobile applications that enable patients to check for drug–drug interactions are of moderate quality and low cost. They did not assess efficacy. An Annual Perspective examined other technological innovations for engaging patients in safety.
Lee TT, Kesselheim AS. Ann Intern Med. 2018;168:730-732.
Innovation is a valuable process in health care. However, when innovations are rapidly deployed, efforts to proactively identify and address safety concerns may fall short and lead to unintended consequences. This commentary describes a new program to expedite the review of digital health software and summarizes the benefits and potential harms that could result from the program.
Dalal AK, Schaffer A, Gershanik EF, et al. J Gen Intern Med. 2018;33:1043-1051.
Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. This cluster-randomized trial used medical record review to assess whether an automated notification of test results to discharging hospitalist physicians and receiving primary care physicians improved follow-up compared with usual care. The intervention was focused on actionable test results, which constituted less than 10% of all pending tests. Even with the intervention, only 60% of tests deemed actionable had any documented follow-up in the medical record, and there was no significant difference compared to usual care. The authors conclude that automated clinician notification does not constitute a sufficient intervention to optimize management of tests pending at discharge. Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations can improve follow-up of abnormal test results.
Howe JL, Adams KT, Hettinger Z, et al. JAMA. 2018;319:1276-1278.
As electronic health records (EHRs) have become ubiquitous, our understanding of their benefits and potential harms has evolved. In particular, issues with EHR usability (the ease of understanding, learning, and using the interface) impair physician workflow and may result in harm to patients. In this study, investigators analyzed voluntary error reports from the Pennsylvania Patient Safety Authority and a multihospital academic health system for evidence of safety issues related to EHR usability. Although limited by the nature of the voluntary reports, which contained sparse details precluding assessment of causal factors, investigators did identify and categorize cases in which problems with EHR usability may have directly resulted in patient harm. Many EHR contracts with health care organizations include "hold harmless" clauses limiting the EHR vendors' legal liability, meaning that patients may not be able to seek compensation if EHR issues directly lead to harm. A WebM&M commentary discussed a case of contrast nephropathy arising in part due to a confusing EHR user interface.