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 73 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.
Chrouser KL, Xu J, Hallbeck S, et al. Am J Surg. 2018;216:573-584.
Stressful clinician interactions can diminish the teamwork required to support safe care. This review describes a framework for guiding understanding of how behavioral and emotional responses can affect team behavior, performance, and patient outcomes in the surgical setting. The authors recommend areas of research required to fully understand the phenomenon.
Stucke RS, Kelly JL, Mathis KA, et al. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Jung JJ, Jüni P, Lebovic G, et al. Ann Surg. 2020;271:122-127.
Analysis of errors in aviation is facilitated by the cockpit "black box," which records flight data as well as communications between team members. This study reports on initial data from the OR Black Box, a novel monitoring technology that integrates continuous monitoring of intraoperative data with video and audio recording of operative procedures. In this initial study of elective laparoscopic procedures, auditory and cognitive distractions were common, and multiple safety events occurred during each procedure.
Joseph A, Bayramzadeh S, Zamani Z, et al. HERD. 2018;11:137-150.
Elements of the work environment can affect the safety of health care delivery. This literature review summarizes research to inform architectural and interior design improvements for operating rooms that support safety. The discussion highlights environmental themes associated with layout, acoustics, and lighting that can affect teamwork, processes, and communication in the operating room.
Wakeman D, Langham MR. Semin Pediatr Surg. 2018;27:107-113.
Crew resource management is a strategy from aviation that has been applied in medicine to enhance teamwork. This review discusses crew resource management as a way to improve communication, establish a safety culture, and reduce morbidity and mortality in the operating room.
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Implement Sci. 2018;13:50.
Checklists have been shown to improve surgical outcomes in clinical trials, but their effectiveness in real-world settings is variable. This implementation study examined factors related to checklist use in the operating room for crises rather than routine practice. Investigators surveyed individuals who downloaded a checklist from two websites about whether they used a checklist regularly in specific clinical situations. Thorough checklist implementation, leadership support, and dedicated staff training time led to more regular use of the checklist. Conversely, frontline resistance and lack of clinical champions undermined checklist use. The authors conclude that optimizing organizational conditions should increase the use of checklists during crises in operating rooms. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Abbott TEF, Ahmad T, Phull MK, et al. Br J Anaesth. 2018;120:146-155.
Surgical checklists have been shown to improve safety outcomes in randomized trials, but implementation studies have not uniformly demonstrated benefit. This study included a large, multicountry observational cohort of surgical outcomes before and after implementation of a checklist. Mortality declined after checklist implementation, but the rate of postoperative complications remained unchanged. Investigators also conducted a meta-analysis of surgical checklist studies (excluding those that paired the checklist with other interventions) on postoperative mortality and complications. This synthesis of published studies suggests that checklists improved mortality and complications overall. Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists in past PSNet interviews.
Chang B, Kaye AD, Diaz JH, et al. J Patient Saf. 2018;14:9-16.
This retrospective study of the National Anesthesia Clinical Outcomes Registry database determined that complications were more common for procedures performed in the operating room compared to procedures performed outside the operating room. This finding may be due to adverse selection, in which patients at higher risk for complications are intentionally treated in the operating room environment. A past WebM&M commentary discussed an adverse event related to a procedure at an outpatient center.
Ravi B, Pincus D, Wasserstein D, et al. JAMA Intern Med. 2018;178:75-83.
Overlapping surgery is the practice of surgeons scheduling distinct procedures on different patients concurrently. This practice has raised safety concerns. This large population-based retrospective study examined outcomes for nonoverlapping versus overlapping hip surgeries across Ontario, Canada. After adjustment for factors known to predict surgical outcomes, such as hospital and surgeon case volume and the patient's overall health, researchers found an association between increasing duration of surgical overlap and higher risk of complications. These results contrast with a recent single-center study that found no safety differences between overlapping and nonoverlapping neurosurgeries. An accompanying editorial acknowledges the mixed results of safety studies for overlapping surgeries and calls for large, multicenter, prospective studies across a range of surgical procedures with long-term follow-up.
George BC, Bohnen JD, Williams RG, et al. Ann Surg. 2017;266:582-594.
Insufficient trainee supervision may lead to adverse events, but lack of autonomy may leave trainee physicians unprepared for independent practice. In this direct observation surgical education study, attending physicians rated readiness for independent practice and level of supervision for surgical trainees performing specific core procedures throughout the course of their training. At the end of training, 90% of trainees performed competently on average complexity patients, but this proportion dropped to less than 80% for the most complex cases. For about two-thirds of core procedures, surgical residents still had significant supervision in their last 6 months of training. The authors raise concerns about whether graduating residents have sufficient experience practicing independently to enter clinical practice. A previous PSNet perspective advocated for continued appropriate supervision to augment patient safety.
Ball JE, Bruyneel L, Aiken LH, et al. Int J Nurs Stud. 2018;78:10-15.
Missed nursing care may result from inadequate nurse staffing and explain the relationship between nurse-to-patient ratios and patient outcomes. Research has shown that higher nurse staffing levels are associated with lower inpatient mortality and that reduced staffing increases the risk for postoperative complications. In this study, investigators examined data from more than 400,000 surgical patients from 300 hospitals in 9 countries as well as survey responses from 26,516 nurses. They found a significant association between nurse staffing and missed nursing care with 30-day risk-adjusted postoperative mortality. The authors conclude that measuring missed nursing care may help identify patients at greater risk for adverse outcomes earlier in their course. A past WebM&M commentary highlighted important issues associated with nurse staffing ratios.
Haynes AB, Edmondson L, Lipsitz SR, et al. Ann Surg. 2017;266:923-929.
Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.
Cooper WO, Guillamondegui O, Hines J, et al. JAMA Surg. 2017;152:522-529.
Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.
Hyder JA, Hanson KT, Storlie CB, et al. Ann Surg. 2017;265:639-644.
Overlapping surgery refers to when two procedures are performed concurrently, but important portions occur at different times. Experts have raised concerns about the safety of scheduling coincident procedures. This study compared overlapping surgeries with nonoverlapping surgeries of the same type at a single referral center. After adjusting for surgeon and patient characteristics, investigators found no differences in inpatient mortality or length of stay. They performed an analogous analysis in the National Surgical Quality Improvement Program registry medical record data, which resulted in similar findings. Although these results should allay concerns about concurrent surgeries, the authors caution that further studies at multiple centers are needed to ensure that overlapping procedure practices do not carry excess risk to patients.
Vadnais MA, Hacker MR, Shah NT, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;43.
Cesarean delivery is associated with increased morbidity, mortality, longer hospital stays, and increased costs. From 2008 through 2015, a single tertiary care academic medical center implemented a quality improvement initiative designed to address factors influencing the rate of nulliparous term singleton vertex (NTSV) cesarean delivery rate. The initiative consisted of provider education, provider feedback, and implementation of new policies. The rate of NTSV cesarean delivery decreased from 34.8% to 21.2% and total cesarean delivery rate decreased from 40.0% to 29.1%. Researchers also noted a decline in the incidence of episiotomy and third-degree lacerations. 
de Jager E, McKenna C, Bartlett L, et al. World J Surg. 2016;40:1842-1858.
The World Health Organization surgical safety checklist garnered a great deal of attention after initial studies showed remarkable reductions in postoperative complication rates. However, subsequent studies failed to reproduce these results, engendering controversy about the true effectiveness of checklists in real-world settings. This systematic review of 25 studies of the surgical safety checklist found that complication rates decreased with checklist usage in resource-poor settings, but the checklist did not appear to be effective in developed nations. The authors also noted that the reported effect of the checklist was incongruous—in several studies, postoperative complications did not decrease, but postoperative mortality improved, raising questions about what mechanism helped the checklist achieve its effect. These concerns, along with methodological problems in many of the included studies, led the authors to postulate that the observed improvements seen in some studies may have been due to temporal changes or other interventions rather than the checklist itself.
Winters BD, Bharmal A, Wilson RF, et al. Med Care. 2016;54:1105-1111.
The ability to use administrative data to measure patient safety is critical, because chart review is time-consuming and resource-intensive. The AHRQ Patient Safety Indicators (PSIs) and the CMS Hospital-acquired Conditions (HACs) aim to measure and track patient safety using administrative data. PSIs are often used for pay-for-performance, and CMS has a policy of nonpayment for hospitalizations associated with HACs. This systematic review found that PSIs and HACs have not been adequately validated compared to chart review and therefore may be subject to coding error. Establishing hospital quality or payment based on unvalidated metrics has consequences for patient safety efforts. These results suggest that unless further development and validation of administrative metrics occurs, widespread implementation of pay-for-performance efforts may not significantly improve patient safety.
Bilimoria KY, Chung JW, Hedges L, et al. New Engl J Med. 2016;374:713-727.
Resident physician duty hour policies have generated rigorous debate, particularly following the most recent ACGME changes implemented in 2011, which shortened maximum shift lengths for interns and increased time off between shifts. This national study cluster-randomized 118 general surgery residency programs to adhere to current ACGME duty hour policies or to abide by more flexible rules that essentially followed the prior standard of a maximum 80-hour work week. Between these two groups, there were no significant differences in patient outcomes, including death and serious complications. Residents reported similar levels of satisfaction with their overall education quality and their well-being. An accompanying editorial notes that the study authors interpret these results as supporting flexible work-hour rules. Alternatively, the editorial author suggests that this study refutes concerns that the new policy compromises patient safety, and as such there is no compelling reason to backtrack on its implementation.
Fan CJ, Pawlik TM, Daniels T, et al. J Am Coll Surg. 2016;222:122-128.
Safety culture is widely measured and discussed, but its link to patient outcomes has not been consistently demonstrated. Surgical site infections are considered preventable adverse events. In this cross-sectional study, investigators found that better safety culture was associated with lower rates of surgical site infections after colon surgery. Specifically, aspects of safety culture associated with teamwork, communication, engaged leadership, and nonpunitive response to error were linked to fewer infections. Although this work does not establish a clear cause-and-effect relationship between safety culture and patient outcomes, it suggests that efforts to enhance safety culture could improve patient outcomes.