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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 - 8 of 8 Results
Müller M, Jürgens J, Redaèlli M, et al. BMJ Open. 2018;8:e022202.
Standardized handoff tools are increasingly implemented to improve communication between health care providers. Although this systematic review identified several studies supporting the use of SBAR as a communication tool to improve patient safety, the authors suggest the evidence is moderate and that further research is needed.
Scott IA, Pillans PI, Barras M, et al. Ther Adv Drug Saf. 2018;9:559-573.
The prescribing of potentially inappropriate medications is a quality and safety concern. This narrative review found that information technologies equipped with decision support tools were modestly effective in reducing inappropriate prescribing of medications, more so in the hospital than the ambulatory environment.
Yardley I, Yardley S, Williams H, et al. Palliat Med. 2018;32:1353-1362.
The frequency and nature of adverse events experienced by patients receiving palliative care remains unknown. In this mixed-methods study, researchers analyzed patient safety incidents among patients receiving palliative care from a national database in England over a 12-year period. They found that pressure ulcers, medication errors, and falls were the most frequently reported types of events and conclude that there is significant opportunity to improve the safety of palliative care.
Scott AM, Li J, Oyewole-Eletu S, et al. Jt Comm J Qual Patient Saf. 2017;43.
Fragmented care transitions may lead to adverse events due to poor provider communication, disjointed continuation of care, and incomplete patient follow-up. In this study, site visits were conducted at 22 healthcare organization across the United State to determine facilitators and barriers to implementing transitional care services. Identified facilitators included collaborating within and beyond the organization, tailoring care to patients and caregivers, and generating buy-in among staff. Barriers included poor integration of transitional care services, unmet patient or caregiver needs, underutilized services, and lack of physician buy-in. Results suggest how institutions may wish to prioritize strategies to facility effective care transitions.
Mody L, Greene T, Meddings J, et al. JAMA Intern Med. 2017;177:1154-1162.
Catheter-associated urinary tract infections are considered preventable never events. This pre–post implementation project conducted in long-term care facilities employed a multimodal intervention, similar to the Keystone ICU project. This sociotechnical approach included checklists, care team education, leadership engagement, communication interventions, and patient and family engagement. The project was conducted over a 2-year period across 48 states. In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract infections, despite no change in catheter utilization, suggesting that needed use of catheters became safer. A related editorial declares this project "a triumph" for AHRQ's Safety Program for Long-term Care.
Ferrah N, Lovell JJ, Ibrahim JE. J Am Geriatr Soc. 2017;65:433-442.
Older adults living in long-term care facilities face significant safety hazards. This systematic review examined medication errors in nursing homes and found a high prevalence of errors overall. The review revealed that a significant number of errors were related to handoffs and that 75% of these older patients received at least one potentially inappropriate medication. However, serious harm associated with medication use was reported for less than 1% of errors. The authors emphasize the difficulty of attributing harm to medications versus underlying illness in nursing home residents, and they call for designing safer systems for medication administration in nursing homes. A previous WebM&M commentary discussed challenges to ensuring patient safety in long-term care facilities.
Page A; Committee on the Work Environment for Nurses and Patient Safety, Board on Health Care Services. Washington, DC: The National Academies Press; 2004. ISBN: 9780309090674.
This AHRQ-funded Institute of Medicine study identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety in nursing care. The report provides a blueprint of actions for all health care organizations that rely on nurses. The report's findings and recommendations address the related issues of management practices, workforce capability, work design, and organizational safety culture.
Bootman JL, Harrison DL, Cox E. Arch Intern Med. 1997;157:2089-96.
This study discusses a statistical model to estimate costs associated with drug-related problems in nursing facilities. Using decision analysis techniques and an expert panel of physicians and pharmacists, investigators designed conditional probabilities attributable to drug therapy. Their findings suggest that, for every dollar spent on drug therapy, nearly $1.33 in health care resources are consumed in the treatment of drug-related problems. The authors conclude that improved collaboration among physicians and pharmacists in the nursing home population is likely to reduce the economic impact of drug-related adverse events.