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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 - 5 of 5 Results
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.
Ford EC, Evans SB. Med Phys. 2018;45:e100-e119.
Learning from adverse events is a core component of patient safety improvement. This review explores the application of this concept in radiation oncology, successful practices, and challenges for incident learning system implementation in the specialty.
Paine CW, Goel V, Ely E, et al. J Hosp Med. 2016;11:136-144.
Alarm safety is now a Joint Commission National Patient Safety Goal. This systematic review analyzed 24 studies on alarm characteristics and 8 studies that evaluated interventions to improve alert fatigue. Consistent with other studies, the vast majority of the time, alarms do not signal problems that require clinician action. The most promising intervention strategies for reducing alarms that have emerged thus far are widening alarm parameters, implementing alarm delays, and frequently changing telemetry electrodes and wires. A PSNet perspective discussed approaches to reduce alert fatigue while maintaining safety.
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.
Collard HR, Saint S, Matthay MA. Ann Intern Med. 2003;138:494-501.
Health care–associated infections (HAIs) are a common adverse event in hospitalized patients and an increasing source of study for preventive strategies. Ventilator-associated pneumonia (VAP) is one of the four most common HAIs along with catheter-related bloodstream infection, catheter-associated urinary tract infection, and surgical site infection. This systematic review provides a series of recommendations to reduce the incidence of VAP, including use of semi-recumbent positioning, sucralfate rather than H2-antagonists, and aspiration of subglottic secretions in select patient populations. The authors point out that while many studies highlight the success of preventive strategies, no randomized trial has evaluated the effects of combining the preventive practices as an additive bundle or checklist.