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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)

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Pérez T, Moriarty F, Wallace E, et al. BMJ. 2018;363:k4524.
Elderly patients are at greater risk of experiencing adverse drug events than the adult population as a whole. Older patients are more likely to be frail, have more medical conditions, and are physiologically more sensitive to injury from certain classes of medication. Researchers examined a large cohort of Irish outpatients age 65 and older to determine the relationship between hospital discharge and potentially inappropriate medication prescribing. Approximately half of the 38,229 patients studied were prescribed a medication in contravention to the STOPP criteria. The risk of potentially inappropriate prescribing increased after hospital discharge, even when using multiple statistical techniques to control for medical complexity. An accompanying editorial delineates various vulnerabilities that predispose older patients to adverse events during the transition from hospital to home. A recent PSNet perspective discussed community pharmacists' role in promoting medication safety.
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.
Martin P, Tamblyn R, Benedetti A, et al. JAMA. 2018;320:1889-1898.
This randomized controlled trial tested a pharmacist-led educational intervention at community pharmacies. Intervention patients received a brochure about potentially inappropriate medications. Discontinuation of potentially harmful medications increased among older adults compared to usual pharmacy care, suggesting that community pharmacies can play a significant role in medication safety.
Bates DW, Singh H. Health Aff (Millwood). 2018;37:1736-1743.
The release of the Institute of Medicine's To Err Is Human in 1999 represented a seminal moment in patient safety and is considered by many to have launched the modern patient safety movement. The report highlighted the incidence of medical errors and preventable deaths in the United States and catalyzed research to identify interventions for improvement. The authors reflect on progress since its publication and suggest that while many effective interventions have been developed for addressing safety challenges such as hospital-acquired infections and medication errors, successful implementation of these solutions remains difficult, and improvement in other areas has been less consistent. In addition, new safety challenges have emerged in the last 20 years including those related to ambulatory care and diagnostic error. The authors conclude that preventable harm remains significant and advocate for enhanced use of widely available electronic data to develop improved interventions for what they foresee may be a Golden Era of swift progress in patient safety. A PSNet perspective reflected on patient safety progress in surgery. The Moore Foundation provides free access to this article.
Meisenberg BR, Grover J, Campbell C, et al. JAMA Netw Open. 2018;1:e182908.
Opioid deaths are a major public health and patient safety hazard. This multimodal, health care system-level intervention to reduce opioid overprescribing consisted of changes to the electronic health record, patient education, and provider education and oversight. Opioid prescribing decreased substantially (58%) systemwide with no discernible decrement in patient satisfaction.
Schwartz SP, Adair KC, Bae J, et al. BMJ Qual Saf. 2019;28:142-150.
Burnout is a highly prevalent patient safety issue. This survey study examined work–life balance and burnout. Researchers validated a novel survey measure for work–life balance by asking participants to report behaviors like skipping meals and working without breaks. Residents, fellows, and attending physicians reported the lowest work–life balance, and psychologists, nutritionists, and environmental services workers reported the highest work–life balance. Time of day and shift length also influenced work–life balance: day shift had better scores compared to night shift, and shorter shifts had better scores than longer shifts. The work–life balance score also clustered by the work setting: individuals with different roles within a given setting (such as the intensive care unit, the emergency department, or the clinical laboratory) had more similar work–life balance. Those with higher work–life balance reported better safety culture and less burnout. The authors suggest that burnout interventions target work settings rather than individuals, because work–life balance seems to function as a shared experience within health care settings.
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.
Gillespie A, Reader TW. Milbank Q. 2018;96:530-567.
Patient voices provide crucial insight into health care safety hazards. Researchers classified 1110 patient complaints submitted to England's National Health Service to identify stages of care where harm occurred. The most common cause of major or catastrophic harm was diagnostic error.
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.
Kale MS, Korenstein D. BMJ. 2018;362:k2820.
Overdiagnosis has emerged as a quality and safety concern due to its potential to result in financial and emotional harm for patients and their families. This review discusses factors that contribute to overdiagnosis in primary care including financial incentives and innovations in diagnostic technologies. The authors recommend increasing awareness about the negative consequences of unneeded screenings, clarifying the definition of overdiagnosis, and adjusting cultural expectations for testing and treatment as avenues for improvement.
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.
Millenson ML, Baldwin JL, Zipperer L, et al. Diagnosis (Berl). 2018;5:95-105.
Recently, several mobile health care applications have been developed and marketed directly to nonclinician consumers. Researchers reviewed the literature regarding direct-to-consumer diagnostic applications. They found wide variation in the safety of these applications and suggest that further research is needed to thoroughly assess their effectiveness.
Chung CP, Callahan T, Cooper WO, et al. Pediatrics. 2018;142:e20172156.
Reducing the incidence of opioid overdoses and overdose deaths is an essential patient safety priority. In the last decade, children have experienced a dramatic rise in hospitalizations and intensive care unit stays for opioid poisoning. Researchers examined outpatient opioid prescriptions to children who did not have serious illnesses like cancer or sickle cell disease in Tennessee between 1999 and 2014. Dentists prescribed the largest share of more than 1 million opioid prescriptions, followed by surgeons. The authors conclude that 1 in every 2611 prescriptions resulted in an emergency department visit or hospitalization. An accompanying editorial contextualizes the study findings and offers suggestions, such as relying on less toxic analgesics for dental procedures and choosing alternatives to codeine for children who need opioids. A past PSNet perspective examined the patient safety implications of the opioid epidemic.
Cheema E, Alhomoud FK, Kinsara ASA-D, et al. PLoS One. 2018;13:e0193510.
Pharmacists often perform medication reconciliation at hospital admission and discharge to prevent medication errors. This meta-analysis examined the efficacy of pharmacist-led medication reconciliation across 18 trials that included more than 6000 patients. Researchers found that pharmacist-led interventions reduced medication discrepancies but did not significantly affect adverse medication events or health care utilization. However, a recent large trial of pharmacist-led medication reconciliation with positive results was excluded from this meta-analysis.
Fiscella K, McDaniel SH. Amer Psychol. 2018;73:451-467.
Teamwork is an important element of safe care delivery. This review explores the evidence on the role of teams in ambulatory care, innovations in primary care teamwork models, and barriers to success. The authors offer recommendations to encourage team development in primary care, including defining team competencies, providing team training opportunities specific to ambulatory care, and adjusting care payment mechanisms.
Ladapo JA, Larochelle MR, Chen A, et al. JAMA Psychiatry. 2018;75:623-630.
Patients prescribed opioids and benzodiazepines concurrently may be at increased risk for adverse drug events. Researchers used data from both the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to identify adults already using a benzodiazepine who were newly prescribed opioid medication between 2005 and 2015. Rates of opioid prescribing among patients using a benzodiazepine remained higher than rates in the general population during the entire study period.
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.
Anderson AM, Matsumoto M, Saul MI, et al. JAMA Dermatol. 2018;154:569-573.
Diagnostic errors among physician extenders are understudied, especially in subspecialty settings. In this study, physician assistants working in dermatology clinics performed more biopsies and diagnosed fewer skin cancers and melanoma than board-certified dermatologists. The authors were unable to assess how often either clinician type missed diagnoses of skin cancer.
Slawomirski L, Auraaen A, Klazinga N. Paris, France: Organisation for Economic Co-operation and Development; 2018.
The global economic impact of medical error is substantial. This report expands on a 2017 analysis to address a gap in understanding about the impact of medical mistakes in ambulatory and primary care environments across 29 countries. The authors found iatrogenic harm and associated disease burden in outpatient care to be concerning and suggest the need for policy and leadership to design and implement improvement strategies.
Gupta N, Vujicic M, Blatz A. J Am Dent Assoc. 2018;149:237-245.e6.
This analysis of claims data from insurers found that rates of opioid prescribing following dental procedures increased between 2010 and 2015. The sharpest rise occurred among 11–18 year olds, and nearly one-third of opioid prescriptions were not associated with surgical procedures. The authors urge limiting use of opioids for nonsurgical dental visits.