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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 126 Results
Fact Sheet/FAQs
Horsham, PA; Institute for Safe Medication Practices: February 2019.
Drawing on information gathered from the ISMP Medication Errors Reporting Program, this fact sheet provides a comprehensive list of commonly confused medication names, including look-alike and sound-alike name pairs. Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions such as the use of tall man lettering in order to prevent such errors. An error due to sound-alike medications is discussed in this AHRQ WebM&M commentary.
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.
Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Steelman VM, Shaw C, Shine L, et al. Jt Comm J Qual Patient Saf. 2019;45:249-258.
An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.
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.
Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.
This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.
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.
Vento S, Cainelli F, Vallone A. World J Clin Cases. 2018;6:406-409.
Malpractice concerns can influence treatment decisions as clinicians seek to avoid errors of omission. This commentary reviews factors that contribute to defensive medicine, underscores the role the blame culture has in perpetuating this behavior, and discusses the costs to patients, physicians, and health systems.
O'Sullivan ED, Schofield SJ. J R Coll Physicians Edinb. 2018;48:225-232.
Cognitive biases can lead to unnecessary treatment and delays in diagnosis. This commentary reviews examples of bias that commonly occur in medical practice and describes debiasing tactics to help improve decision-making.
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.
Organizational Policy/Guidelines
Emerging Classic
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. Am J Health-Syst Pharm. 2018;75:1493-1517.
Pharmacists can play an important role in medication error reduction efforts across health care systems. This document provides recommendations and best practices for health-system pharmacists to improve safety throughout the medication-use process.
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.
Korenstein D, Chimonas S, Barrow B, et al. JAMA Intern Med. 2018;178:1401-1407.
Overuse of tests and treatments can contribute to negative consequences for patients. This commentary suggests that clarification is required to engage clinicians in reducing overuse-related harm and proposes a six-domain framework that delineates areas of concern to target improvement strategies. A previous WebM&M commentary highlighted a case in which health care overuse resulted in a patient's death.
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.
Schnipper JL, Mixon A, Stein J, et al. BMJ Qual Saf. 2018;27:954-964.
The goal of medication reconciliation is to prevent unintended medication discrepancies at times of transitions in care, which can lead to adverse events. Implementing effective medication reconciliation interventions has proven to be challenging. In this AHRQ-funded quality improvement study, five hospitals implemented a standardized approach to admission and discharge medication reconciliation using an evidence-based toolkit with longitudinal mentorship from the study investigators. The toolkit was implemented at each study site by a pharmacist and a hospitalist with support from local leadership. The intervention did not achieve overall reduction in potentially harmful medication discrepancies compared to baseline temporal trends. However, significant differences existed between the study sites, with sites that successfully implemented the recommended interventions being more likely to achieve reductions in harmful medication discrepancies. The study highlights the difficulty inherent in implementing quality improvement interventions in real-world settings. A WebM&M commentary discussed the importance of medication reconciliation and suggested best practices.
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.
Kale MS, Korenstein D. BMJ. 2018;362:k2820.
Overdiagnosis has emerged as a quality and safety concern due to its potential to result in financial and emotional harm for patients and their families. This review discusses factors that contribute to overdiagnosis in primary care including financial incentives and innovations in diagnostic technologies. The authors recommend increasing awareness about the negative consequences of unneeded screenings, clarifying the definition of overdiagnosis, and adjusting cultural expectations for testing and treatment as avenues for improvement.
Redmond P, Grimes TC, McDonnell R, et al. Cochrane Database Syst Rev. 2018;8:CD010791.
This systematic review identified 25 randomized controlled trials of methods to improve medication reconciliation at the time of hospital discharge, most of which involved a pharmacist-mediated intervention. Overall, there was no clear evidence that medication reconciliation interventions reduced either medication discrepancies or adverse drug events. A previous commentary discussed the challenges in implementing effective medication reconciliation programs in real-world settings.
Shahid S, Thomas S. Saf Health. 2018;4.
Situation, Background, Assessment, Recommendation (SBAR) is a mnemonic used to structure information sharing to avoid communication failures during handoffs. This review examines the challenges and benefits associated with SBAR use and provides a comparative assessment with other standardized communication tools in the field.