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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 - 13 of 13 Results
Barr D, Epps QJ. J Thromb Thrombolysis. 2019;47:146-154.
Anticoagulants are commonly prescribed medications that have high potential for harm if administered incorrectly. This review summarizes common errors at the prescribing, dispensing, and administration phases of direct oral anticoagulant therapy. The authors suggest team-based strategies—such as process assessment, policy development, and medication reconciliation—to prevent adverse drug events associated with direct oral anticoagulants.
Schiff GD, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
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.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Bruera E. N Engl J Med. 2018;379:601-603.
Well-intentioned system-level efforts to improve care can result in unintended consequences. This commentary discusses the adverse effects of strategies to address the opioid epidemic, such as tightened regulations that led to opioid shortages. The author highlights how the shortages of certain parenteral opioids can cause patient harm and describes clinical and policy suggestions to improve the reliability of care amid efforts to manage the opioid crisis.
World Health Organization; Organisation for Economic Co-operation and Development; OECD; World Bank.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Haffajee RL, Mello MM, Zhang F, et al. Health Aff (Millwood). 2018;37:964-974.
The opioid epidemic is a well-recognized national patient safety issue. High-risk opioid prescribing can contribute to misuse. Provider prescribing has come under increased scrutiny and several states have implemented prescription drug monitoring programs (PDMPs). Prior research suggests that such programs have the potential to reduce opioid-related harm. This study used commercial claims data to assess the impact of PDMPs implemented in four states in 2012–2013 on opioid prescribing. By the end of 2014, all four states with PDMPs demonstrated a greater reduction in the average amount of morphine-equivalents prescribed per person per quarter compared with states without these programs. One state demonstrated a decrease in the percentage of people who filled an opioid prescription. The authors conclude that PDMPs have the potential to reduce opioid use and improve prescribing practices. An Annual Perspective highlighted safety issues associated with opioid medications.
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and Development; 2018.
The global economic impact of medical error is substantial. This report expands on a 2017 analysis to address a gap in understanding about the impact of medical mistakes in ambulatory and primary care environments across 29 countries. The authors found iatrogenic harm and associated disease burden in outpatient care to be concerning and suggest the need for policy and leadership to design and implement improvement strategies.
Haas S, Gawande A, Reynolds ME. JAMA. 2018;319:1765-1766.
Changes in organizational process and governance can create downstream conditions that result in failures. This commentary explored how system expansion affects safety. The authors highlight the need for leadership to use system data to plan for and manage the impact of the resultant infrastructure and patient population changes on care delivery.
Thomas LR, Ripp JA, West CP. JAMA. 2018;319:1541-1542.
Clinician burnout is a growing concern with known patient safety implications. This commentary describes a charter for health care organizations to prioritize physician well-being in order to preserve quality and safety of patient care. The charter includes elements known to contribute to safety, such as a positive work culture and leadership engagement. The authors call for reducing time spent on documentation and administration, consistent with prior studies. A related editorial emphasizes the importance of the physician–patient relationship in creating meaning and joy in physician work. A previous PSNet interview and perspective discussed the relationship between physician professional satisfaction and patient safety.
Vadnais MA, Hacker MR, Shah NT, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;43.
Cesarean delivery is associated with increased morbidity, mortality, longer hospital stays, and increased costs. From 2008 through 2015, a single tertiary care academic medical center implemented a quality improvement initiative designed to address factors influencing the rate of nulliparous term singleton vertex (NTSV) cesarean delivery rate. The initiative consisted of provider education, provider feedback, and implementation of new policies. The rate of NTSV cesarean delivery decreased from 34.8% to 21.2% and total cesarean delivery rate decreased from 40.0% to 29.1%. Researchers also noted a decline in the incidence of episiotomy and third-degree lacerations. 
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, cluster-randomized trial to determine the most effective approach for reducing the rates of MRSA was implemented in 43 hospitals, including 74 ICUs and 74,256 patients. Compared to baseline, modeled hazard ratios for MRSA clinical isolates were 0.92 for those undergoing screening isolations, 0.75 for targeted decolonization, and 0.63 for universal decolonization. Universal decolonization resulted in significantly greater reduction in blood stream infections than the other two studied approaches for infection reduction.
Gaba DM, Howard SK. New Engl J Med. 2002;347:1249-1255.
Acknowledging the inevitable connection between fatigue and patient safety, Gaba and Howard examine the policies for work hours for clinicians-in-training in the United States. At the time of publication, regulations varied by specialty and, despite policies limiting work hours, many residency-training programs did not comply with these limited standards. On the heels of increasing proposals to regulate work hours set forth by house staff, lobbying organizations, and Congress, the Accreditation Council for Graduate Medical Education (ACGME) announced new requirements for limited work hours beginning July 2003 for all residency programs. The authors discuss the likely consequences of these limitations, including decreased work force, increased hand-offs, and restrictions on moonlighting. Specific challenges, including behavioral and cultural shifts as well as potential economic impact, are discussed.