Skip to main content

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 48 Results
Carayon P, Wooldridge A, Hose B-Z, et al. Health Aff (Millwood). 2018;37:1862-1869.
System and process weaknesses can hinder safe patient care. This commentary raises awareness of human factors engineering as a key opportunity for enhancing patient safety. The authors provide recommendations to drive adoption and spread of human factors strategies through targeted education, clinician–engineer partnerships, and coordinated improvement efforts.
Yu K-H, Kohane IS. BMJ Qual Saf. 2019;28:238-241.
Use of artificial intelligence (AI) and computer algorithms as tools to improve diagnosis have both risks and benefits. This commentary explores challenges to implementing AI systems at the front line of care in a safe manner and identifies weaknesses of advanced computing systems that influence their reliability.
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.
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.
Bajaj K, Minors A, Walker K, et al. Simul Healthc. 2018;13:221-224.
Frontline simulations offer valuable opportunities to explore system issues, process weaknesses, and teamwork skills. This article discusses risks associated with in situ simulations and describes how to determine when simulations should be canceled, postponed, or relocated to ensure safety.
Woods DD, Dekker S, Cook R, Johannesen L. Boca Raton, FL: CRC Press; 2017. ISBN: 9781317175537.
"Human error," the authors of this book argue, is an inherently misleading term.  Drawing on the field of complexity science, the authors contend that viewing error as a definable and measurable entity fails to account for the complex social and organizational dynamics that allow errors to occur. In this viewpoint, approaches to improving patient safety that focus on measuring adverse events and limiting variability are inherently limited, as they only measure practitioners' behaviors and do not account for the organizational characteristics and influences that establish a culture of safety. The book uses insights from high-reliability organizations and the field of human factors engineering to establish a new paradigm for analyzing safety across a variety of industries.
Dekker S. Boca Baton, FL: CRC Press; 2017.
This revised and reorganized book provides a primer on how human error causes mishaps and often illustrates deeper troubles within a system. Both the old view of human error that places blame on the individual and the new view that identifies most human failures as merely a symptom of systems-level problems are presented. This view of human error has led to the application of root cause analyses and human factors engineering in health care. New chapters discuss the importance of safety culture and provide recommendations on improving the failure investigation process.
Carayon P, ed. Boca Raton, FL: CRC Press; 2017. ISBN: 9781439830338
Human factors principles are widely applied in high-risk industries to promote safety and are increasingly adapted by health care organizations to improve patient safety. This book provides an in-depth analysis of the intersection of design and process with the human element of health care to underscore their effects on patient safety and introduce strategies for improvement. The authors cover a wide range of health care topics including medical technology and telemedicine. A past PSNet perspective discussed the application of human factors engineering concepts.
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015. ISBN-13: 9781118862414.
According to Weick and Sutcliffe, high-reliability organizations operate under challenging conditions yet experience fewer problems than would be anticipated as they have developed ways of "managing the unexpected" better than most organizations. The authors, professors at the University of Michigan School of Business, use both case studies and theory-based analysis to explain the methods that result in organizational mindfulness, and, through it, a more robust culture of safety. This third edition of their classic text provides individual chapters on each of the five elements of high reliability and pays increased attention to the roles of interaction, sensemaking, and language in achieving more reliable performance under risky conditions.
Sittig DF, Classen DC, Singh H. J Am Med Inform Assoc. 2015;22:472-8.
The Institute of Medicine and the Food and Drug Administration have called for the establishment of a national organization to oversee health information technology (IT) safety in the United States. This commentary, written by leaders in the IT field, recommends goals for the proposed Office of the National Coordinator-based Health IT Safety Center, including monitoring and tracking safety events, investigating incidents and disseminating guidance, building a process and infrastructure to examine the safety of health IT systems, and generating support for vigilance around health IT safety in the public and private sectors. The authors also highlight the convening ability of such a center as a critical component for transforming the safety of health IT.
Hollnagel E. Aldershot, Hampshire, England: Ashgate; 2014. ISBN: 9781472423085.
Historically, the approach to patient safety has been more reactive rather than proactive, involving a response to adverse events and near misses after they occur. This book covers two perspectives of safety: a reactive approach that emphasizes reducing adverse outcomes and a proactive approach that focuses on ensuring actions go as planned. The author discusses how each approach has been applied in health care and other high-risk industries. A PSNet perspective explored what health care can learn from aviation, another high-risk industry.
Russ SJ, Sevdalis N, Moorthy K, et al. Ann Surg. 2015;261:81-91.
The initial introduction of the World Health Organization surgical safety checklist was associated with impressive improvements in patient safety. However, more recently a study of the government-supported implementation of the checklist in Canada showed no beneficial effect. This study examined the mandated introduction of the surgical safety checklist in hospitals across England and discovered large variation in how the checklist was initially implemented. The most common barrier encountered was resistance from senior clinicians. The authors provide generalizable recommendations to guide the future implementation of improvement efforts. A recent PSNet interview with Dr. Lucian Leape discussed his perspective on the effect and implementation of checklists for patient safety.
Meeks DW, Smith MW, Taylor L, et al. J Am Med Inform Assoc. 2014;21:1053-9.
Health information technology is being rapidly utilized in the clinical environment, with recent data showing that most hospitals and clinics have implemented some form of electronic health record (EHR). In this context, this report from the Veterans Health Administration's Informatics Patient Safety Office is timely, as it uses a sociotechnical framework that takes into account both technical aspects and human factors engineering principles to analyze 100 safety incidents relating to the EHR. The authors found four categories of system flaws: mismatches between user needs and information displays, errors arising from software modification or updates, failures at the interface between the EHR and other clinical systems, and hidden dependencies within the system itself. Most of these issues were identified long after the EHR was implemented, highlighting the need for ongoing monitoring and optimization of EHRs to ensure their safety capabilities are being maximized. An error caused in part by lack of interoperability between two clinical information systems is discussed in a prior AHRQ WebM&M commentary.
Ahmed N, Devitt KS, Keshet I, et al. Ann Surg. 2014;259:1041-53.
The 2011 duty hour regulations for resident physicians were intended to improve patient safety by reducing resident fatigue. Examining the effects of duty-hours reform on surgical trainees, this systematic review concluded that there were no improvements in patient outcomes. Both perceived education and performance on certification exams have declined following reform, and more frequent handoffs have led to safety concerns. Even though some improvements in residents' quality of life were observed after the first duty-hours reform, the subsequent limitation of 16-hour shifts has not enhanced well-being. The authors express concern about current surgery residency training and urge caution prior to reforming graduate medical education further. A previous AHRQ WebM&M perspective explored the impact of duty hours on patient safety.
Mello MM, Boothman RC, McDonald T, et al. Health Aff (Millwood). 2014;33:20-29.
When a patient is a victim of an error, hospitals have traditionally followed a "deny and defend" strategy, providing limited information to the patient and family and avoiding admissions of fault—or even admission that an error occurred. This approach has long been criticized for its lack of patient-centeredness, and in response some institutions have begun to implement communication-and-response strategies that emphasize early disclosure of adverse events and proactive attempts to resolve the situation. This study reviews six institutions' experiences with two types of communication-and-response strategies: early settlement programs (in which errors are fully disclosed and an offer of compensation is made, along with investigation of safety issues) and limited reimbursement programs (which provided limited compensation to patients with concerns about their care, but explicitly exclude more severe errors). Through structured interviews with key participants, the authors identify crucial regulatory, legal, and practical issues with implementing these programs. They emphasize that such programs should be viewed as part of an effort to improve safety culture and that transparency and a blame-free approach are essential to obtaining support (especially from physicians). The complex intersection between error disclosure and malpractice is explored further in an AHRQ WebM&M perspective.
Millar R, Mannion R, Freeman T, et al. Milbank Q. 2013;91:738-70.
Hospital leadership oversight is thought to be critical for advancing patient safety initiatives. This narrative review synthesized 122 studies examining the role of hospital board oversight in fostering safety practices. Investigators found that high-performing hospitals are more likely to have skilled board members and standardized board processes compared with low-performing hospitals, highlighting the value of effective and committed leadership that prioritizes quality and safety improvement. However, more research is needed to determine optimal hospital governance. A past AHRQ WebM&M interview discussed the role of leadership and medical administration in patient safety.
Dixon-Woods M, Baker R, Charles K, et al. BMJ Qual Saf. 2014;23:106-15.
Achieving an organizational safety culture is a widely espoused goal. The authors of this study synthesized qualitative and quantitative data from interviews, surveys, ethnographic case studies, board minutes, and publicly available datasets to describe the extent of safety culture in the United Kingdom's National Health Service (NHS). Culture was inconsistent across the NHS and barriers to safety culture included competing priorities, redundant regulatory and compliance requirements, lack of timely and actionable data, suboptimal organizational and information systems, and variations in staff and leadership commitment. The accompanying editorial highlights the finding that safety culture is mostly local, with high and low performing units existing within the same institution. The authors propose three actions to foster a safety culture: engagement of health care providers, establishment of peer networks, and explicit commitment between clinicians and leadership to prioritize safety.
Meeks DW, Takian A, Sittig DF, et al. J Am Med Inform Assoc. 2014;21:e28-e34.
Electronic health record (EHR) implementation can be associated with both risks and improvements in safety. This study sought to characterize the positive and negative safety implications of EHR implementation and ongoing use by analyzing interview data from a 30-month evaluation of EHR implementation at 12 sites in the United Kingdom's National Health Service. The study demonstrates how eight specific human–technological factors in a sociotechnical model (people, workflow and communication, internal organizational features, external rules and regulation, measurement and monitoring, hardware and software, clinical content, human–computer interface) come into play in moving health care organizations through three phases of technology implementation. Safety hazards may be introduced in early phases of EHR implementation phases, and inappropriate use of technology as implementation progresses can also result in risks. When EHR use has stabilized, the technology can be used to promote safety.
Drolet BC, Christopher DA, Fischer SA. N Engl J Med. 2012;366:e35.
Over the past decade, increasing duty-hour regulations for resident physicians have been motivated by efforts to improve patient care, resident education, and resident quality of life. Despite mixed results in achieving those goals, the 2011 regulations extended the work hour limits further and added a significant cost burden to teaching institutions in covering provider gaps. This survey study captured more than 6200 responses from a diverse group of resident physicians to assess the impact of the newest regulations. Overall, nearly half the residents disapprove of the regulations, and nearly 60% report that their hours worked are unchanged compared to last year. Other notable findings included that 43% reported no change in the quality of care, more than half believed preparation for more senior roles was worse, and only 16% believed education was improved. Not surprisingly, 72% reported increased handoffs, and only interns reported improvements in their quality of life. The authors conclude that a one-size-fits-all approach that comes with such regulations may not meet the needs of all trainees or training environments.
Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General; November 2010. Report No. OEI-06-09-00090.
Hospitalized patients continue to suffer iatrogenic harm, according to this study of Medicare patients completed by the Office of the Inspector General (OIG). Using methodology similar to the landmark Harvard Medical Practice Study, this study found that 13.5% of hospitalized Medicare patients experienced an adverse event, of which nearly half were considered preventable. However, fewer than 2% of patients experienced either a never event or a preventable complication for which hospitals are no longer reimbursed by the Centers for Medicare and Medicaid Services. These results are similar to the OIG's prior 2008 report. Based on these results, OIG recommends further efforts to accurately measure adverse events, and also recommends broadening the "no pay for errors" policy. The challenges of accurately measuring safety problems are discussed in an AHRQ WebM&M commentary.