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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 29 Results
Kron K, Myers S, Volk L, et al. Am J Health-syst Pharm. 2018;75:774-783.
Misinterpretation of medication instructions can lead to medication administration errors and patient harm. Current computerized provider order entry for medications does not support best practices for medication instructions. This study describes an expert panel process to delineate how to include the indication—the reason for prescribing the medication—in the medication instructions. Experts recommend that prescribing begin with the indication for the medication, with decision support that promotes selection of the optimal medication. The authors emphasize the importance of a streamlined electronic prescribing process. A past PSNet perspective discussed integrating clinician decision support systems to improve medication safety.
Brenner SK, Kaushal R, Grinspan Z, et al. J Am Med Inform Assoc. 2016;23:1016-36.
Health information technology (IT) has had a profound impact on health care. Although health IT has led to efficiency gains and improved safety, unintended consequences remain a concern. In this systematic review, researchers analyzed 69 studies from 2001 through 2012 that examined the use of health IT in a clinical setting and its effect on safety outcomes for patients. About one-third of the studies demonstrated a positive impact of health IT on patient safety outcomes, but many of these focused on the hospital setting, involved a single institution, and looked at decision support or computerized provider order entry. The authors suggest that future studies should focus on other areas in which the impact of health IT remains understudied, such as in outpatient and long-term care settings, and they underscore the need for higher quality research. A recent WebM&M commentary described the unintended consequences of health IT.
Schiff GD, Amato MG, Eguale T, et al. BMJ Qual Saf. 2015;24:264-71.
This study used a two-stage approach to analyze the effectiveness of computerized provider order entry (CPOE) at preventing medication errors in real-world settings. The investigators analyzed data from the MEDMARX database in order to identify the types of medication errors caused by computerized order entry. From these data, the researchers developed 21 examples of problematic orders and tested whether they could be entered in a range of commercial CPOE systems. The majority of orders were entered successfully and quickly, without the CPOE system generating any alerts or requiring clinicians to use only minor workarounds to enter the order. Even when the CPOE system did generate an alert, these could generally be overridden by clinicians without changing the order. The study findings mirror those of a prior simulation study and highlight the importance of real-world usability testing for health information technology. Although CPOE systems have been shown to reduce prescribing errors, this study's results indicate that the safety benefits of CPOE may not be achieved without careful implementation and ongoing evaluation.
Carayon P, Wetterneck TB, Cartmill R, et al. BMJ Qual Saf. 2014;23:56-65.
As the patient safety field matures, there is increasing recognition of the need to incorporate human factors engineering methods into analyzing errors and developing solutions. These methods were used to investigate the types and frequency of medication errors in two intensive care units. Although existing medication safety interventions have mainly targeted errors at individual stages of the medication management process (e.g., computerized provider order entry [CPOE] to prevent prescribing errors), this study found that in many cases, errors occurred in an interdependent fashion at multiple stages of the process. For example, incorrect transcription of an order could then lead to a medication administration error. While CPOE is likely a solution for a significant proportion of errors, this study's results indicate a need for closed-loop systems that can minimize the risk of all types of medication errors.
Sittig DF, Singh H. Arch Intern Med. 2011;171:1281-4.
Efforts to implement health information technology (HIT) continue at a rapid pace, particularly for electronic health records and computerized provider order entry systems. However, studies have demonstrated the unintended consequences of HIT and new errors they create. This commentary takes a sociotechnical approach to highlight the origins of HIT errors, which the authors characterize as malfunctions during use, incorrect use by individuals, and insufficient interaction between HIT and another system component. The authors provide a detailed framework that applies sociotechnical model dimensions (e.g., hardware/software, clinical content, workflow, human–computer interface) to examples of errors and potential ways to reduce their incidence. A past AHRQ PSNet perspective discussed HIT and patient safety with national expert Dr. David Bates.
Nanji KC, Rothschild JM, Salzberg C, et al. J Am Med Inform Assoc. 2011;18:767-73.
Medication safety in the ambulatory setting is an ongoing challenge, partly driven by the lack of computerized systems that promote safe prescribing. This retrospective cohort study analyzed nearly 4000 computer-generated prescriptions over a 4-week period and found a 12% error rate; 35% were considered potential adverse drug events. The error rates varied for different computerized systems (ranging from 5% to 38%) with omitted information the most common error type (60%). The findings suggest that implementing e-prescribing solutions requires more than simply adopting a computerized system. Careful attention is required to assure safe processes and functionality.
Schiff GD, Galanter WL, Duhig J, et al. Arch Intern Med. 2011;171:1433-1440.
Strategies to prevent medication errors are an ongoing focus in patient safety. Computerized provider order entry, medication reconciliation, avoidance of drug–drug interactions, and bar-coded medication administration are a few areas generating significant attention. This review discusses an alternate approach to medication safety, focusing on prevention of prescribing unnecessary medications at the outset. The authors provide a set of principles that urge clinicians to: think beyond drugs, practice more strategic prescribing, maintain heightened awareness about side effects, exercise skepticism about new drugs, work with patients for a shared agenda, and consider long-term impacts of medications prescribed. Each of these principles is discussed and sets the background for a recommendation to shift current paradigms in prescribing from "newer and more is better" to "fewer and more time tested is best."
Strom BL, Schinnar R, Aberra F, et al. Arch Intern Med. 2010;170:1578-83.
Computerized provider order entry (CPOE) systems prevent prescribing errors by warning clinicians about medication interactions or contraindications. However, extensive research has shown that clinicians ignore many warnings, especially those perceived as clinically inconsequential. In this randomized trial, investigators created a "hard stop" warning that essentially prevented co-prescribing of warfarin and trimethoprim-sulfamethoxazole (a combination that exposes patients to severe bleeding risks). Although the hard stop was much more successful than a less stringent warning at preventing co-prescribing, the trial was stopped and the warning abandoned because several patients experienced delays in needed treatment with one of the drugs. The accompanying editorial by Dr. David Bates points out that this study vividly illustrates the unintended consequences of CPOE, a persistent issue that has slowed the pace of CPOE implementation.
Poon EG, Keohane CA, Yoon CS, et al. New Engl J Med. 2010;362:1698-1707.
Information technology solutions have proven effective at reducing some types of medication errors. For example, computerized provider order entry (CPOE) can reduce errors at the prescribing and transcription stages. Barcoding of medications has been advocated as a means of reducing medication administration errors; although some studies have found success, others have noted unintended consequences. This study tested a closed-loop system that combined CPOE, barcoding, and an electronic medication administration record in an academic medical center and found that the system significantly reduced administration errors as well as potential adverse drug events. The authors note that significant changes in workflow were necessary to achieve these results and caution that successful use of this technology requires considerable attention to development and implementation.
Longhurst CA, Parast L, Sandborg CI, et al. Pediatrics. 2010;126:14-21.
Computerized provider order entry (CPOE) has been enthusiastically endorsed as a means of preventing medication errors, and some studies have shown clinical benefits associated with its use. However, a growing body of literature demonstrates that CPOE implementation may have many unintended consequences affecting clinician workflow, and these issues may account for the mixed safety performance of CPOE. This study, conducted at an academic tertiary care hospital, found that overall inpatient mortality decreased after CPOE was launched, with an estimated 36 lives saved in the first 18 months after implementation. These findings counter an earlier, widely cited study in which mortality increased after CPOE installation, and point to the importance of careful attention to the implementation process to ensure that CPOE meets its potential.
Metzger J, Welebob E, Bates DW, et al. Health Aff (Millwood). 2010;29:655-663.
Computerized provider order entry (CPOE) has provided significant safety benefits in research studies, especially when combined with clinical decision support to prevent common prescribing errors. However, CPOE's "real-world" performance has been mixed, with high-profile studies documenting a variety of unintended consequences. This AHRQ-funded study used simulated patient records to evaluate the ability of eight commercial CPOE modules to prevent medication errors. The overall results were disappointing, as CPOE failed to prevent many medication errors—including fully half of potentially fatal errors, which are considered never events. The individual CPOE products varied significantly in their ability to detect potential errors. Some hospitals did achieve superior performance, which the authors ascribe to greater experience with CPOE and implementation of more advanced decision support tools. Another recent article found that reminders within CPOE systems resulted in only small improvements in adherence to recommended care processes. Taken together, these studies imply that CPOE implementation may not result in large immediate effects on safety and quality in typical practice settings.
Shojania KG, Jennings A, Mayhew A, et al. CMAJ. 2010;182:E216-25.
Computerized provider order entry (CPOE) is one of the most widely recommended—and underutilized—safety strategies in health care. Prior research has argued that CPOE must be combined with decision support, ideally at the point of care, in order to effectively change clinician behavior. However, this meta-analysis of 32 trials of point-of-care computer reminders found only small overall improvements in adherence to target processes of care. A few trials reported much larger improvements, but the reasons for this are unclear, probably reflecting a combination of specific system and reminder design features, and perhaps cultural or contextual features of the institutions. Until further research identifies the specific design and contextual factors that reliably predict clinically worthwhile improvements in care, hospitals implementing CPOE may continue to find themselves conducting exercises in trial and error.
Walsh KE, Landrigan CP, Adams WG, et al. Pediatrics. 2008;121:e421-e427.
Studies of the effect of computerized physician order entry (CPOE) in pediatrics have reached conflicting results. This study evaluated the impact of a commercial CPOE system on medication errors over a 16-month time frame. Strengths of this study included use of a comprehensive error-finding method and a time-series analytical approach. Implementation of the CPOE system was associated with a modest reduction in "nonintercepted" serious medication errors (errors that were not detected, and thus affected the patient), but there was no overall decrease in injuries suffered due to adverse drug events. Notably, the rate of dosing errors—the most common type of pediatric drug error—did not decrease, despite specific features of the CPOE system designed to prevent such errors. The authors discuss their experience with the system and subsequent modifications that have been made in response to these results.
Kaushal R, Shojania KG, Bates DW. Arch Intern Med. 2003;163:1409-16.
Computerized physician order entry (CPOE) systems hold the promise of potentially reducing medication errors, especially when coupled with clinical decision support systems (CDSS) that guide clinicians' medication ordering practices. This systematic review did find substantial reductions in potential medication errors in studies of both CPOE and CDSS systems. However, the few studies found were not adequately powered to determine the effects on adverse drug events requiring clinical intervention, and chiefly assessed the effects of "home-grown" CPOE systems. The studies also provided only limited information on implementation issues and potential unintended consequences of CPOE. Such issues will need to be addressed in order to improve the slow pace of uptake of CPOE in US hospitals.
Ash JS, Sittig DF, Poon EG, et al. J Am Med Inform Assoc. 2007;14:415-23.
While implementation of computerized provider order entry systems is widely recommended, prior research has raised the concern that CPOE may lead to unintended effects on patient safety. In this study, the authors sought to classify the frequency of unintended consequences—positive and negative—encountered in hospitals that have implemented CPOE. Unintended consequences were classified based on the authors' previously developed taxonomy. Survey respondents felt that unintended consequences were widespread, primarily relating to changes in provider workflow and communication. Failure to anticipate these issues may have played a role in widely publicized instances of problems with CPOE implementation.
Campbell EM, Sittig DF, Ash JS, et al. J Am Med Inform Assoc. 2006;13:547-56.
This qualitative study describes the capture and analysis of computerized provider order entry (CPOE)–related events from five different CPOE sites. Building on an initial set of examples from an expert panel, investigators designed a 9-category classification scheme for nearly 325 unintended consequences reported. The most frequent unintended consequences included more or new work for clinicians, workflow issues, and never-ending system demands. The authors discuss strategies to address each of the categories and explain the importance of understanding these issues to advance management of future CPOE applications. A past study and commentary discussed the need for caution with implementation of CPOE systems in light of similar concerns and available research.
Aspden P, Wolcott J, Bootman JL, et al, eds; Institute of Medicine, Committee on Identifying and Preventing Medication Errors. Washington DC: National Academies Press; 2007. ISBN 0309101476.
A major report by the Institute of Medicine (IOM) on medication errors suggests that, despite all the progress in patient safety since To Err is Human, medication errors remain extremely common, and the health care system can do much more to prevent them. Among the startling statistics from this report: more than 1.5 million Americans are injured every year in American hospitals, and the average hospitalized patient experiences at least one medication error each day. The report emphasizes actions that health care systems, providers, funders, and regulators can take to improve medication safety. These actions include having all US prescriptions written and dispensed electronically by 2010, more widespread use of medication reconciliation, and additional research on drug errors and how to prevent them. Importantly, the report also emphasizes actions that patients can take to prevent medication errors, such as maintaining active medication lists and bringing their medications to appointments. Support for the IOM report came from the Centers for Medicare & Medicaid Services.
McDonald CJ. Ann Intern Med. 2006;144:510-6.
This case study shares the events of a near miss when a patient almost received a fatal dose of insulin in response to another patient's reported hyperglycemia. Ironically, the root cause of the problem involved a new bar-coding system to prevent errors in patient identification. The authors discuss the case in detail and advise caution in the implementation of new technology (eg, computerized provider order entry), which may solve safety issues but create the opportunity for others. This article is part of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors.
Kaushal R, Jha AK, Franz C, et al. J Am Med Inform Assoc. 2006;13:261-6.
Implementation of computerized physician order entry (CPOE) continues to stimulate national interest despite the costs associated with its adoption. This study estimated a cumulative net savings of nearly $17 million over a 10-year period after CPOE use. Investigators from Brigham and Women's Hospital in Boston discovered that the most financially beneficial aspect of CPOE involved the level and type of clinical decision support available. For instance, the capacity to provide renal drug dosing, specific drug guidance, and mechanisms for prevention of adverse events all served as important contributors to the estimated savings. The authors argue a business case for CPOE adoption exists both for financial reasons and for patient safety. A past commentary discussed the benefits, costs, and issues related to CPOE for organizations considering implementation.
Han YY, Carcillo JA, Venkataraman ST, et al. Pediatrics. 2005;116:1506-12.
Although computerized physician order entry (CPOE) prescribing systems are commonly believed to improve patient safety and outcomes, this single-hospital study discovered increased mortality rates after implementation. Investigators retrospectively analyzed several variables in the 13 months before and 5 months following implementation. Even after adjustment for mortality variables, CPOE was independently associated with 3.28 greater odds for mortality. Additional findings include the workflow challenges and increased time required to enter orders compared with traditional handwritten practices. Given the national interest in CPOE, these findings should reinforce the understanding that CPOE is a tool rather than a solution for patient safety and that appropriate vigilance in implementation is necessary.