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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 - 12 of 12 Results
Lyons I, Furniss D, Blandford A, et al. BMJ Qual Saf. 2018;27:892-901.
Errors and discrepancies in intravenous infusions were common in this study performed at two English hospitals, but only a small proportion of errors led to patient harm. The use of smart pumps did not appear to protect against errors.
Mody L, Greene T, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Saint S, Greene T, Krein SL, et al. New Engl J Med. 2016;374:2111-2119.
The landmark Keystone ICU study, which achieved remarkable sustained reductions in central line–associated bloodstream infections in intensive care unit (ICU) patients, stands as one of the most prominent successes of the patient safety field. Although the use of a checklist gathered the most publicity, the study's key insight was that preventing health care–associated infections (HAIs) required extensive attention to improving safety culture by addressing the socioadaptive factors within hospitals that contributed to HAIs. In this new AHRQ funded national study, the Comprehensive Unit-based Safety Program was implemented at 603 hospitals in 32 states, with the goal of preventing catheter-associated urinary tract infections in ICU and ward patients. The effort involved socioadaptive interventions (various approaches shown to improve safety culture) and technical interventions (targeted training to reduce usage of indwelling urinary catheters and providing regular data feedback to participating units). Catheter usage and infection rates significantly decreased in ward patients, although no change was found in ICU patients. This study thus represents one of the few safety interventions that has achieved a sustainable improvement in a clinical outcome. An earlier article described the implementation of the program, which involved collaboration between state and national agencies and academic centers. In a 2008 PSNet interview, the study's lead author discussed his work on preventing HAIs.
Dixon-Woods M, Bosk CL, Aveling EL, et al. Milbank Q. 2011;89:167-205.
The remarkable success of the Keystone ICU project was initially publicized as an example of the power of checklists. While checklists are a useful safety tool, this study used an ethnographic approach to better understand the sociological factors that helped the project succeed. The authors highlight the densely networked community, the multimodal interventions, the data-driven processes, and the reframing of catheter-related blood stream infections as a social problem as important contextual factors that must be considered in quality improvement efforts. These lessons are especially important given that subsequent studies have found difficulty in implementing checklists in the absence of a robust safety culture.
Pronovost PJ, Goeschel CA, Colantuoni E, et al. BMJ. 2010;340:c309.
This study demonstrated that reduced rates of catheter-related bloodstream infections persisted 18 months after participation in the landmark Keystone ICU project. The findings provide strong evidence for the impact and sustainability of a multifaceted quality improvement (QI) initiative that popularized checklists, generated controversy over the relationship between QI and research, and led to a 2009 Eisenberg award for the Keystone Center. Dr. Pronovost, lead author of this study and principal investigator of the Keystone project, was interviewed in 2005 by AHRQ WebM&M.
Bosk CL, Dixon-Woods M, Goeschel CA, et al. Lancet. 2009;374:444-5.
Discussing the impact of checklists in the broader context of frontline care, the authors emphasize that achieving safer care requires more than simple checklists.
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.
Catheter-related bloodstream infections (CRBSI) remain a common and deadly patient safety issue in intensive care units (ICUs), although prior research has defined several effective preventive strategies. In the “Keystone ICU” project, funded by the Agency for Healthcare Research and Quality (AHRQ), 103 ICUs in Michigan participated in a statewide safety initiative, including instituting five evidence-based preventive strategies recommended by the Centers for Disease Control and Prevention (CDC). The project focused on changing provider behavior through addressing safety culture, incorporating a centralized education program for team leaders at each institution, and closely collaborating with infection control personnel. The intervention was remarkably successful, nearly eliminating CRBSI entirely in most ICUs over an 18-month follow-up period. A related editorial lauds the success of the intervention and calls for all U.S. hospitals to adopt similar programs.
Rothschild JM, Keohane CA, Cook F, et al. Crit Care Med. 2005;33:533-540.
This prospective, randomized time series trial examined the impact of smart pumps with integrated decision support on adverse medication events. Investigators used a decision support system that allowed categorization of noted events by type, preventability, and severity. Despite finding similar serious medication error rates in both study groups, opportunities for intervention were discovered through improved detection with the new technology. The authors concluded that improved infusion safety can result from incorporating novel technology but stressed that behavioral and educational factors of users must be considered.
Norman DA. New York, NY: Doubleday; 1988. ISBN: 9780385267748.
Norman, a cognitive psychologist, outlines the elements of effective user-centered design, which include making the inner workings of devices visible, exploiting natural function, controlling relationships, and using constraints successfully. Through both fable and anecdote, Norman illustrates forcing functions and how bad design can exacerbate the consequences of human error. This classic text is a valuable introduction to the role of design in patient safety.
Tenner E. New York, NY: Knopf; 1996. ISBN: 0679425632.
Tenner’s discussions of medical and nonmedical examples provide an engaging introduction to the many ways in which new technologies can have unintended consequences. Side effects of any technology are well known and well studied. What interests Tenner, however, are “revenge effects,” which he defines as the exact opposite of the intended effects of a new technology. For instance, the widespread availability of computers in offices and homes was heralded as ushering in a new, paperless world. Instead, paper use sky-rocketed. From a safety perspective, numerous examples exist in which making something safer simply encouraged more reckless behavior. Health care examples often involve a safer version of a drug or procedure, which then becomes overused. At the population level, then, adverse events do not decrease and may even increase. For instance, laparoscopic cholecystectomy is a much less morbid procedure than open cholecystectomy. It is this feature of the laparoscopic procedure that resulted in a significant increase in the number of patients referred for removal of their gallbladder, to the point that morbidity and mortality at the population level did not improve as a result of this major advance in surgical technology.
Cook RI, Woods DD. Hum Factors. 2006;38:593-613.
New technology continues to offer great advances and challenges. This article takes a detailed look at technology’s impact on human performance by studying the implementation of a new physiological monitoring system for use in cardiac anesthesia. Discussion includes characteristics of the upgraded system, a process-tracing technique to examine the complex physician-computer interaction, and the problems that developed while in use. The authors introduce a number of new cognitive burdens that resulted and discuss how providers attempted to overcome these burdens within the framework of the new system. Though it represents one example, the rich discussion in this article applies to most new technology and the human factors that require it to function as technically designed.
Samore MH, Evans S, Lassen A, et al. JAMA. 2004;291:325-34.
This study evaluated methods for medical device event surveillance to help identify and classify an important source of adverse events. Investigators used a number of different strategies to capture device-related events, which included a computer-based system, discharge codes (ICD-9), work logs, and patient survey results. They analyzed more than 7000 identified problems and discovered that very few events were captured by more than one surveillance strategy. Their findings suggest that voluntary reporting alone vastly underestimates the rate of medical device-related errors. Furthermore, future investigation to better understand the incidence and nature of such events must occur to frame necessary prevention efforts.