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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 26 Results
Gates M, Wingert A, Featherstone R, et al. BMJ Open. 2018;8:e021967.
Fatigue among health care workers is a well-established safety issue that can increase risk of errors. Investigators conducted a systematic review to examine the effects of fatigue on both providers and patients, as well as the impact of efforts designed to mitigate fatigue. They ultimately included 47 studies in their analysis, 28 of which demonstrated a relationship between fatigue or inadequate sleep and physician health outcomes. Looking at six cohort studies and patient outcomes, they found no difference in patient mortality or postoperative complications between surgeons who were and were not sleep deprived. A past PSNet interview discussed how research on sleep deprivation among residents has informed duty hour changes.
Carthon MB, Hatfield L, Plover C, et al. J Nurs Care Qual. 2019;34:40-46.
This cross-sectional study found that nurses reporting a lower level of engagement also described worse patient safety in their work environment. These concerns were exacerbated when higher patient–nurse staffing ratios were present. The authors suggest that increasing nurse engagement may improve patient safety.
Patterson ES. Hum Factors. 2018;60:281-292.
Poor design of health information technology can lead to miscommunication, burnout, and inappropriate documentation. This review of the literature identified three practice deviations associated with health IT, including workflow disruption, inappropriate use of text fields, and use of handwritten paper or whiteboard notes instead of health IT. The author recommends improvements focused on electronic health record display to enhance communication.
Desai SV, Asch DA, Bellini LM, et al. New England Journal of Medicine. 2018;378.
Duty hour reform for trainees was undertaken to improve patient safety. However, experts have raised concerns that duty hour limits have reduced educational opportunities for trainees. This study randomized internal medicine residency programs to either standard duty hour rules from the Accreditation Council on Graduate Medical Education (ACGME) or less stringent policies that did not mandate the maximum shift length or time off between shifts. Investigators found that trainees in both groups spent similar amounts of time in direct patient care and educational activities, and scores on examinations did not differ. Interns in flexible duty hour programs reported worse well-being and educational satisfaction compared to those working within standard duty hours. As in a prior study of surgical training, program directors of flexible duty hour programs reported higher satisfaction with trainee education. These results may help allay concerns about detrimental effects of duty hour reform on graduate medical education. A PSNet perspective reviewed changes to the ACGME requirements to create flexibility for work hours within the maximum 80-hour workweek.
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.
Shanafelt TD, Boone S, Tan L, et al. Arch Intern Med. 2012;172:1377-85.
Professional burnout—cynicism and a loss of enthusiasm and sense of accomplishment at work—has been shown to be common among both physicians and nurses. This cross-sectional survey of more than 7000 physicians found that burnout among physicians is more common than in the general population, with emergency physicians and primary care physicians the most commonly afflicted. Burnout has been shown to be one of several emotional influences on patient safety; it has also been linked to medical errors and disruptive behavior.
Reed DA, Fletcher KE, Arora VM. Ann Intern Med. 2010;153:829-42.
Duty hour regulations that take effect in July 2011 will limit first-year residents' shift length to 16 hours, cap the consecutive night shifts that can be worked, and encourage protected sleep time. This systematic review found that while reducing shift length has some effect on patient safety, existing literature does not indicate the optimal shift length or the magnitude of benefit for patients or physicians. A past AHRQ WebM&M perspective and interview discussed the role of medical education in improving patient safety.
Nasca TJ, Day SH, Amis S, et al. N Engl J Med. 2010;363:e3.
This article summarizes the Accreditation Council for Graduate Medical Education's proposed new regulations on housestaff duty hours. The recommendations are perhaps most notable for what they do not contain—a reduction in the 80-hour weekly limit. Rather than narrowly focusing on duty-hour restrictions, the recommendations take a broad approach to maximizing patient safety in training environments through targeted reductions in work hours for first-year residents, enhanced supervision by attending physicians, standardizing expectations around handoffs and signouts, and engaging residents in safety and quality improvement efforts. Although the current 80-hour work week will be preserved, the new regulations would eliminate extended-duration shifts for first-year residents (as was recommended in a 2008 Institute of Medicine report). The current regulations, implemented in 2003, have improved residents' quality of life but have not positively impacted patient safety or educational outcomes. The ACGME acknowledged this evidence in crafting recommendations that seek to establish a culture of safety within residency programs and focus more broadly on enhancing supervision for early-stage residents while allowing more autonomy for senior trainees.
Rothschild JM. JAMA. 2009;302.
Limitations on housestaff duty hours were implemented with the intent of protecting patients by reducing errors made by fatigued residents. Indeed, prior studies have shown that sleep-deprived residents are more prone to committing errors and inadvertently sustaining needlestick injuries. However, comparatively little attention has been paid to the effect of fatigue on attending physicians. Conducted at a single academic medical center, this study evaluated the relationship between sleep deprivation (defined as having operated the night before the scheduled procedure) and complication rates for a range of surgical, obstetric, and gynecologic procedures. There was no overall link between fatigue and complications, but the complication rate was increased for surgeons who had the opportunity to sleep less than 6 hours. Other studies have found that fatigue is influenced by many factors other than hours worked, and therefore further reductions in shift length (as called for in a recent Institute of Medicine report) may not significantly improve patient safety.
Ulmer C, Wolman DM, Johns MME, eds. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedule to Improve Patient Safety, Institute of Medicine. Washington, DC: The National Academies Press; 2008. ISBN: 9780309127721.
The 2003 regulations limiting housestaff work hours have had a profound impact on residency training. Although clinical outcomes appear to be unaffected, faculty and residents have expressed concern that education has been harmed, and the regulations' effect on patient safety remains unclear. The Institute of Medicine's report bases its recommendations on the growing body of research linking clinician fatigue and error, and recommends eliminating extended-duration shifts (defined as more than 16 hours), increasing days off, and improving sleep hygiene by reducing night duty and providing more scheduled sleep breaks. The report estimates that approximately $1.7 billion would be required to hire additional staff to allow residency programs to adhere to these recommendations. A related editorial discusses the balance between patient safety, resident safety, and resident education that was central to the development of these recommendations.
Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-53.
The 2003 regulations that mandated 80-hour work week restrictions have generated significant debate over their impact on patient safety, fatigue, and discontinuity in care. This prospective study examined the role of intern workload and discovered that increased responsibilities were associated with greater sleep loss, longer shift durations, and less participation in educational activities. Investigators also determined that overnight duties during the week and early in the academic year were most problematic, a situation that is likely to worsen in the face of further work hour reductions being proposed. The authors advocate for greater research into workload, concerted efforts to minimize the administrative tasks of trainees, and thoughtful policies that balance patient safety and resident education.
Landrigan CP, Fahrenkopf AM, Lewin D, et al. Pediatrics. 2008;122:250-258.
Regulations intended to reduce resident physicians' work hours have been accompanied by controversy since their introduction in 2003. Although large-scale studies have demonstrated that the regulations were not associated with adverse clinical outcomes, their effect on patient safety remains unclear. This prospective cohort study combined data on actual hours worked and burnout (voluntarily reported by pediatric residents at three hospitals), with data on medication errors gathered through active surveillance. The most notable finding was that, despite the regulations, residents' total hours worked and sleep habits did not change. Extended-duration shifts (of more than 24 hours) remained common, and the majority of residents met the criteria for burnout, although the incidence did decrease. Medication errors and self-reported medical errors did not improve. The authors interpret these findings as demonstrating a need for further reduction in extended-duration shifts, which have been associated with an increased rate of errors.
Jagsi R, Weinstein DF, Shapiro J, et al. Arch Intern Med. 2008;168:493-500.
The patient safety effects of 2003 regulations reducing housestaff work hours have yet to be determined, although emerging evidence indicates that clinical outcomes have been unaffected. This survey queried residents before and after implementation of the work hour regulations regarding their experiences with medical errors, and found that self-reported errors did not decrease even when work hours were significantly reduced. This finding is similar to a previous study. Interestingly, despite considerable concern that reducing work hours would lead to increased discontinuity in patient care, residents did not feel that errors due to handoffs or cross-coverage increased after their work hours were reduced.
Landrigan CP, Czeisler CA, Barger LK, et al. Jt Comm J Qual Patient Saf. 2007;33:19-29.
Efforts to comply with resident work-hour restrictions have placed a significant burden on hospitals and training programs, particularly in addressing the impact of these restrictions on patient safety. This AHRQ-supported study provides a framework to address the scheduling practices that aim to minimize sleep deprivation, optimize teamwork, and promote patient safety. The authors share a number of case examples and discuss policy implications around developing evidence-based scheduling and systematic culture change. This study’s lead author, Dr. Christopher Landrigan, was featured in a past AHRQ WebM&M conversation that discussed the role of sleep deprivation in residency training and its effect on medical errors.
Horwitz LI, Kosiborod M, Lin Z, et al. Ann Intern Med. 2007;147:97-103.
The 2003 regulations reducing housestaff duty hours have been controversial. Although some research has shown fewer errors when housestaff worked shorter shifts, many commentators have raised concern about the potential for errors associated with more transfers of care between physicians. This study sought to directly examine the effect of duty hours limitations on clinical outcomes by comparing medical patients hospitalized on a resident service to patients on a non-teaching service before and after duty hour reduction. There was no detectable increase in adverse events among patients cared for by residents, and some outcomes improved (eg, potential medication errors). Another study in the same issue also found reduced inpatient mortality among medical (but not surgical) patients after implementation of duty hour limitations. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Shetty KD, Bhattacharya J. Ann Intern Med. 2007;147:73-80.
The Accreditation Council for Graduate Medical Education's 2003 regulations limiting housestaff duty hours likely improved residents' quality of life, but the effect on patients has been controversial. A prior review did not find evidence linking reduced work hours to improved patient safety. This study analyzed administrative data from 591 community hospitals before and after implementation of duty hours limitations to determine their effect on inpatient mortality. Mortality was reduced among medical patients in teaching hospitals (compared with non-teaching hospitals) after duty hour limitations came into effect, but no such changes were seen in surgical patients. Another study published in the same issue found improvements in some clinical outcomes among medical patients at a single teaching hospital. The accompanying editorial discusses these two studies in the context of growing evidence that limiting work hours "does no harm" to patients.
Government Resource
Agency for Healthcare Research and Quality; AHRQ
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
Gilbreth FB
This study was one of the first "time-motion" studies of physicians, and pioneered the application of human factors engineering and industrial principles to medical practice. The authors shadowed surgeons, who are described as "the most interesting of all mechanics," at hospitals in the United States, Canada, and Germany. Based on their observations, the authors identified the components of the work day as "necessary work," "unnecessary work," "avoidable delay," and "unavoidable delay." In order to maximize the efficiency of a typical surgical practice, they argue for standardization of surgical equipment and the hospital environment, recommend scheduled rest periods to avoid fatigue, and advocate for using technology to avoid fatigue arising from necessary work.
Weinger MB, Ancoli-Israel S. JAMA. 2002;287:955-7.
This review discusses evidence for the role sleep deprivation plays on performance in both laboratory and clinical settings. The authors define sleep deprivation and summarize past research that suggests the impact is greatest on mood and cognitive tasks rather than motor tasks. They also summarize how fatigue can diminish clinical performance and why this factor poses a significant patient safety concern. Implications from their findings call for greater attention to fatigue in clinical settings and the importance of physicians' acknowledging such states as a risk to their patients rather than a sign of personal weakness. Following publication of this review, two studies evaluated the same relationship in anesthesiology residents and medical interns.
Sexton JB. BMJ. 2002;320.
This study describes self-reported perceptions of teamwork among operating room and intensive care unit staff as well as those of an airline cockpit crew. In the medical setting, investigators discovered tremendous variation in teamwork perceptions that followed traditional hierarchies. While surgical attendings and residents rated teamwork high, anesthesiology attendings rated it lower, as did surgical nurses and anesthesia residents in decreasing order. The authors also note that discussing errors seems to be a greater challenge in medicine than in aviation, which may derive from the fact that aviation participants acknowledged that fatigue and stress negatively impact job performance. While the findings draw only from survey results and make no connection to actual errors in practice, they do generate support for a safety culture in medicine similar to that of the aviation field.