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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 - 7 of 7 Results
Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-7.
Retained foreign objects (RFOs) are a rare but serious complication of surgical procedures. While radiofrequency detection systems, intraoperative radiographic screening, and bar coding have been described as strategies to prevent these occurrences, simple counting may not be as effective. This study examined more than 190,000 operations performed and found an actual RFO rate of 1 per 5,500 operations. Investigators discovered that the majority of RFOs occurred in patients with reportedly correct counts and even in patients who underwent intraoperative imaging. The authors advocate for new technologies that improve upon current imperfect systems to prevent RFOs. A case of an error of a retained sponge and a preventable death was discussed in an AHRQ WebM&M commentary.
Taylor BB, Marcantonio ER, Pagovich O, et al. Med Care. 2008;46:224-228.
Prior research has demonstrated that problems with service quality—for example, waits and delays, poor communication, and poor amenities—are common in hospitals. While patients tend to identify these issues when surveyed about problems they perceive with the quality of care they receive, no relationship has yet been identified between service quality and patient safety. This AHRQ-funded study used retrospective chart review to correlate patients' complaints of poor service quality with documented adverse events and found that patient-reported instances of poor service quality were associated with double the risk of medical errors. The authors hypothesize that some factors associated with the quality of medical care, such as communication between team members, may also be reflected in service quality.
Makary MA, Mukherjee A, Sexton B, et al. J Am Coll Surg. 2007;204:236-43.
Although wrong-site surgeries are rare, they have devastating consequences for patients and are often a harbinger of serious safety problems within an institution. The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing a "time out" before beginning surgery to ensure that all operating room personnel are familiar with the patient, the procedure, their role, and how to respond to complications. In this study, operating room personnel were surveyed regarding their perception of the risk of wrong-site surgery before and after institution of timeouts. Respondents felt teamwork improved and the overall risk for wrong-site surgery decreased after implementing the protocol. An Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses the factors contributing to a near-miss wrong-site surgery.
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.
Carthey J, de Leval MR, Reason JT. Ann Thorac Surg. 2001;72:300-5.
This review discusses the importance of human factors research in reducing adverse events. Drawing from experiences in cardiac surgery, the authors detail the process of capturing and examining various error types. They use case examples to illustrate specific incidents and demonstrate the utility of a systems approach to uncover solutions. The authors also share lessons learned from exploring similar high-complexity industries. They suggest that the profession must better refine methods for prospective analysis of surgical performance and for retrospective analysis of near misses and critical incidents.
Bates DW, Cullen DJ, Laird N, et al. JAMA. 1995;274:29-34.
The authors report on their seminal 1993 study of adverse drug events (ADEs) at the Massachusetts General Hospital and Brigham and Women’s Hospital in Boston. Using 11 intensive and general care units at the two hospitals, the authors prospectively identified actual and potential ADEs by contemporaneous chart review, provider interview, and voluntary incident reporting. The authors report an adjusted rate of ADEs of 6.5 per 100 admissions, 1.8 per 100 considered preventable. Among preventable ADEs, none were fatal, but 43% were judged serious and 20% life threatening. The authors break down ADEs by drug class and by the stage at which the error occurred (ordering, transcription, dispensing, or administration). This study has become the basis for the rationale for implementing computerized physician order entry systems (CPOE), barcoded medication administration systems, and other systems designed to reduce preventable medication errors at each stage.
Chang A, Schyve PM, Croteau RJ, et al. Int J Qual Health Care. 2005;17:95-105.
The rapid increase in research and publications on patient safety following the landmark Institute of Medicine report resulted in the need for a common set of definitions and terminology for patient safety concepts.  To achieve this goal, the authors developed a taxonomy based on a systematic literature review.  The taxonomy, which has been widely accepted since its publication, consists of 5 primary classifications that can be used to classify an error:  impact, type, domain, cause, and prevention or mitigation.