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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 67 Results
O'Connor K, Neff DM, Pitman S. Eur Psychiatry. 2018;53:74-99.
Clinician burnout has been associated with decreased job satisfaction. Burnout may also be detrimental to patient safety. This systematic review and meta-analysis found high rates of burnout among mental health professionals. The authors recommend strategies to address burnout including promoting professional autonomy, developing teamwork, and providing quality clinical supervision.
Edmondson AC. Hoboken, NJ: John Wiley & Sons, Inc.; 2019. ISBN: 9781119477266.
Psychological safety is foundational to sharing ideas, reporting errors, and raising concerns. This book provides a framework for leaders to develop psychological safety in their organization. The author argues that it is imperative to facilitate an environment that enables staff to freely exhibit the candor, comfort, and openness needed to sustain high performance and innovation.
Giardina TD, Haskell H, Menon S, et al. Health Aff (Millwood). 2018;37:1821-1827.
Reducing harm related to diagnostic error remains a major focus within patient safety. While significant effort has been made to engage patients in safety, such as encouraging them to report adverse events and errors, little is known about patient and family experiences related specifically to diagnostic error. Investigators examined adverse event reports from patients and families over a 6-year period and found 184 descriptions of diagnostic error. Contributing factors identified included several manifestations of unprofessional behavior on the part of providers, e.g., inadequate communication and a lack of respect toward patients. The authors suggest that incorporating the patient voice can enhance knowledge regarding why diagnostic errors occur and inform targeted interventions for improvement. An Annual Perspective discussed ongoing challenges associated with diagnostic error. The Moore Foundation provides free access to this article.
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.
Fisher KA, Smith KM, Gallagher TH, et al. BMJ Qual Saf. 2019;28:190-197.
Patients are frequently encouraged to engage with health care providers as partners in safety by speaking up and sharing their concerns. Although research has shown that patients and family members sometimes identify safety issues that might otherwise go unnoticed, they may not always be willing to speak up. In this cross-sectional study involving eight hospitals, researchers used postdischarge patient survey data to understand patients' comfort in voicing concerns related to their care. Almost 50% of the 10,212 patients who responded to the survey reported experiencing a problem during hospitalization, and 30% of those patients did not always feel comfortable sharing their concerns. An Annual Perspective summarized approaches to engaging patients and caregivers in safety efforts.
Dyrbye LN, Burke SE, Hardeman RR, et al. JAMA. 2018;320:1114-1130.
Physician burnout threatens the well-being and sustainability of the health care workforce. This large prospective cohort study found that 45% of resident physicians experienced burnout. Higher burnout rates were detected in urology, general surgery, emergency medicine, and neurology residents (relative to internal medicine residents). The overall prevalence of burnout was similar to studies of practicing physicians, and significantly higher than studies of the general population. Although most residents were satisfied with their career choice, those who were burned out were more likely to regret their decision to become a physician. An Annual Perspective explored how burnout impacts patient safety.
Cooper J, Williams H, Hibbert P, et al. Bull World Health Organ. 2018;96:498-505.
The World Health Organization International Classification for Patient Safety enables measurement of safety incident severity. In this study, researchers describe how they adapted the system to primary care. Their harm severity classification emphasizes psychological harm, hospitalizations, near misses, and uncertain outcomes in addition to traditional markers of harm.
Smith CD, Corbridge S, Dopp AL, et al. NAM Perspectives. Washington DC: National Academy of Medicine; 2018.
Teamwork can contribute to a healthy and respectful work environment. This discussion paper reviews evidence-based characteristics of high-functioning teams and barriers to their optimization in health care. Strategies to enhance teamwork and consequently clinician well-being include improvements in workflow, health information technologies, and financial models to train and sustain teams.
Lane MA, Newman BM, Taylor MZ, et al. J Patient Saf. 2018;14:e56-e60.
The second victim phenomenon refers to the emotional and psychological toll experienced by clinicians who are involved in an adverse event. Peer support has been shown to benefit second victims, especially if initiated promptly after an adverse event. This study describes the implementation and early effects of a second victim peer support program at an academic medical center, which involved training physicians and advanced practice providers as peer supporters. A WebM&M interview with Dr. Albert Wu discussed ways that organizations can support second victims.
Piccardi C, Detollenaere J, Bussche PV, et al. Int J Equity Health. 2018;17:114.
Although prior research suggests that racial and ethnic disparities in health care place certain patients at increased risk for adverse events in the inpatient setting, less is known about the effect of such disparities in the outpatient setting. This systematic review found that vulnerable populations including women and minorities are more likely to experience adverse events in primary care.
Bell SK, Roche SD, Mueller A, et al. BMJ Qual Saf. 2018;27:928-936.
A critical component of strong safety culture is that patients and families feel empowered to speak up about safety concerns. Patients and families are often the first to notice changes in their well-being and consistently identify unique adverse events that are not detected through provider-driven means. This cross-sectional survey asked patients currently hospitalized in an intensive care unit (ICU) and their families about their comfort discussing safety concerns with their health care team, then validated those responses with an Internet-recruited nationwide cohort of patients and families who had been previously cared for in ICUs. Many current ICU patients and families expressed some reticence to speak up. Common reasons cited were concern that the health care team was too busy, fear of being labeled a troublemaker, and worry that the team would judge them for not understanding the medical details of their care.
Commentary
Emerging Classic
Brown SM, Azoulay E, Benoit D, et al. Am J Respir Crit Care Med. 2018;197:1389-1395.
This commentary explores the results of a multidisciplinary discussion on the intersection of "respect" and "dignity" as requirements of safe care. The authors provide recommendations to encourage a strong system-level commitment to respect and dignity, which include the need to expand the research on respect in the intensive care unit and the value of responding to failures of respect as safety incidents to design mechanisms for improvement.
Alingh CW, van Wijngaarden JDH, van de Voorde K, et al. BMJ Qual Saf. 2019;28:39-48.
This study developed a measure of patient safety leadership style for nurse managers. Researchers found that their measure of control-based versus commitment-based safety management was valid and reliable after testing among clinical nurses.
Tawfik DS, Profit J, Morgenthaler TI, et al. Mayo Clin Proc. 2018;93:1571-1580.
Physician burnout is a highly prevalent patient safety concern. Researchers employed data from the American Medical Association to survey United States physicians about burnout and safety. Of 6586 respondents, 54% reported burnout symptoms, consistent with prior studies. More than 10% of respondents reported a major medical error in the prior 3 months, and these rates were even higher among physicians that had symptoms of burnout, even after adjustment for personal and practice factors. The majority of physicians graded their work unit safety as excellent or very good. The authors conclude interventions to improve safety must address both burnout and work unit safety. Because the survey response rate was less than 20%, it is unclear whether these findings reflect practicing US physicians more broadly. An Annual Perspective summarized the relationship between clinician burnout and patient safety.
Patel P, Martimianakis MA, Zilbert NR, et al. Acad Med. 2018;93:769-774.
Semi-structured interviews of 15 surgical residents revealed that surgical trainees may feel pressured to exhibit certain characteristics they perceive as consistent with the ideal surgical personality. The authors suggest that trainee education should acknowledge the impact of the sociocultural context of the surgical environment on trainees.
Williford ML, Scarlet S, Meyers MO, et al. JAMA Surg. 2018;153:705-711.
Physician burnout is widespread and may adversely affect patient safety. This cross-sectional survey study of surgery residents and attendings across 6 general surgery training programs found that 75% of residents met criteria for burnout and more than one-third met criteria for depression. The majority of attendings underestimated the prevalence of both burnout and depression among surgical trainees participating in the study.
Eriksson J, Gellerstedt L, Hillerås P, et al. J Clin Nurs. 2018;27:e1061-e1067.
Overcrowding in the emergency department can compromise patient safety. This qualitative study across five emergency departments found that nurses perceive prolonged stays in the emergency department to adversely affect both patient safety and their ability to provide high-quality care.
Edwards MT. Am J Med Qual. 2018;33:502-508.
Just culture is a movement to shift from blame for errors and instead focus on system issues in order to enhance event reporting and learning from failures. This study examined a survey about just culture in conjunction with Hospital Compare quality ratings and AHRQ's Hospital Survey on Patient Safety Culture. The vast majority of the 270 hospitals that responded to the survey reported adopting just culture. However, respondents reported no improvement in nonpunitive response to error, indicating that a culture of blame persists. The study also found no association between hospital quality ratings and just culture implementation. The author concludes that just culture is not sufficient to create a blame-free culture in hospitals. An Annual Perspective reviewed the context of the no-blame movement and the recent shift toward a framework of a just culture.
Thomas LR, Ripp JA, West CP. JAMA. 2018;319:1541-1542.
Clinician burnout is a growing concern with known patient safety implications. This commentary describes a charter for health care organizations to prioritize physician well-being in order to preserve quality and safety of patient care. The charter includes elements known to contribute to safety, such as a positive work culture and leadership engagement. The authors call for reducing time spent on documentation and administration, consistent with prior studies. A related editorial emphasizes the importance of the physician–patient relationship in creating meaning and joy in physician work. A previous PSNet interview and perspective discussed the relationship between physician professional satisfaction and patient safety.
O'Hara JK, Reynolds C, Moore S, et al. BMJ Qual Saf. 2018;27:673-682.
Patients' reports of safety concerns can reveal adverse events that would not be identified otherwise. In this cluster-randomized trial of patient engagement, patient volunteers read and classified incident reports submitted by hospitalized patients enrolled in the study. Following classification by patients, reports underwent a standardized, validated review by multiple researchers to determine if the event constituted a patient safety incident. Overall, about one-third of patient-reported concerns were deemed to be patient safety incidents. Medication safety issues were the most prevalent concerns. The authors conclude that patient reporting of safety events lends a unique and necessary perspective to error reporting. A previous PSNet perspective highlighted the advantages to and limitations of engaging patients in patient safety.