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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 - 4 of 4 Results
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.
Wu AW. BMJ. 2000;320:726-727.
This editorial coined the term "second victim" to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. Subsequent research has shown that involvement in an error adversely affects providers' emotional health and job satisfaction, and increases risk of burnout. Inspired by these findings, organizations have now developed innovative approaches for supporting second victims, primarily through encouraging debriefing and open discussion of errors. An AHRQ WebM&M commentary discusses the effect of committing a wrong-site procedure error on a resident physician.
Conway J, Federico F, Stewart K, Campbell MJ. Cambridge, MA: Institute for Healthcare Improvement; 2011.
This white paper encourages hospitals to proactively develop and integrate a clinical crisis management plan into their organizational structure. It emphasizes the importance of full disclosure of adverse events, the role of leadership in developing a culture of safety, and the need for organizations to have a comprehensive crisis plan in place rather than reacting after events have occurred. The article provides a checklist and work plan for organizations to use in developing their plan, emphasizing that while their primary responsibility is to the patient and family, they should not neglect the second victims of adverse events—the frontline clinicians involved in the error.
Scott SD, Hirschinger LE, Cox KR, et al. Jt Comm J Qual Saf. 2010;36:233-240.
Rapid response systems (RRS) continue to penetrate hospitals nationally as a method to rescue patients experiencing imminent clinical deterioration. This study takes the same model and describes the context for and development of an innovative RRS to care for the second victim—a health care provider involved in an unanticipated adverse event, medical error, or patient-related injury. The authors surveyed faculty and staff at their institution and found that 39% were familiar with the term second victim and 30% reported personal problems in the past 12 months resulting from their involvement in a patient safety event. More than 80% of respondents expressed a desire for internal rather than external support when needing assistance. Early learnings from a second victim RRS are described, including training of "clinician lifeguards" and monitoring of the interventions. A past AHRQ WebM&M commentary explored how providers recover from their involvement in medical errors.