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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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Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
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.
Organizational Policy/Guidelines
Emerging Classic
Billstein-Leber M, Carrillo CJD, Cassano AT, et al. Am J Health-Syst Pharm. 2018;75:1493-1517.
Pharmacists can play an important role in medication error reduction efforts across health care systems. This document provides recommendations and best practices for health-system pharmacists to improve safety throughout the medication-use process.
Murphy DR, Meyer AN, Sittig DF, et al. BMJ Qual Saf. 2019;28:151-159.
Identifying and measuring diagnostic error remains an ongoing challenge. Trigger tools are frequently used in health care to detect adverse events. Researchers describe the Safer Dx Trigger Tools Framework as it applies to the development and implementation of electronic trigger tools that use electronic health record data to detect and measure diagnostic error. The authors suggest that by identifying possible diagnostic errors, these tools will help elucidate contributing factors and opportunities for improvement. They also suggest that, if used prospectively, such tools might enable clinicians to take preventive action. However, to design and implement these electronic trigger tools successfully, health systems will need to invest in the appropriate staff and resources. A past PSNet perspective discussed ongoing challenges associated with diagnostic error.
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.
Fønhus MS, Dalsbø TK, Johansen M, et al. Cochrane Database Syst Rev. 2018;9:CD012472.
Engaging patients in their care can enhance safety, quality, and satisfaction. The Joint Commission and Centers for Medicare and Medicaid Services both call for health care organizations to encourage patient engagement in their care. This review and meta-analysis assessed which patient engagement strategies improve clinician adherence to recommended clinical practice. Two strategies had moderate impact: enhancing the information elicited from patients and educating patients about best clinical practice. Patient decision aids did not affect clinician performance, and the authors were unable to determine how interventions impacted health outcomes. A PSNet perspective explored novel avenues for patient engagement that leverage health information technology.
Papadopoulos I, Koulouglioti C, Ali S. Contemp Nurse. 2018;54:425-442.
Robotics are increasingly used to assist in both complicated and routine activities in health care. Although safety hazards associated with robotic technologies have been explored in surgery, risks related to purely assistive devices is understudied. This review highlights clinician perspectives regarding assistive robots in health care and highlights infection control and reliability issues as concerns associated with their use.
Schiff GD, Martin SA, Eidelman DH, et al. Ann Intern Med. 2018;169:643-645.
Safe diagnosis is a complex challenge that requires multidisciplinary approaches to achieve lasting improvement. The authors worked with a multidisciplinary panel to build a 10-element framework outlining steps that support conservative diagnosis. Recommendation highlights include a renewed focus on history-taking and physician examination, as discussed in a PSNet perspective. They also emphasize the importance of continuity between clinicians and patients to build trust and foster timely diagnosis. Taken together with recommendations for enhanced communication between specialist and generalist clinicians and more judicious use of diagnostic testing, this report is a comprehensive approach to reducing overdiagnosis and overtreatment.
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.
Gates M, Wingert A, Featherstone R, et al. BMJ Open. 2018;8:e021967.
Fatigue among health care workers is a well-established safety issue that can increase risk of errors. Investigators conducted a systematic review to examine the effects of fatigue on both providers and patients, as well as the impact of efforts designed to mitigate fatigue. They ultimately included 47 studies in their analysis, 28 of which demonstrated a relationship between fatigue or inadequate sleep and physician health outcomes. Looking at six cohort studies and patient outcomes, they found no difference in patient mortality or postoperative complications between surgeons who were and were not sleep deprived. A past PSNet interview discussed how research on sleep deprivation among residents has informed duty hour changes.
Mitchell BG, Gardner A, Stone PW, et al. Jt Comm J Qual Patient Saf. 2018;44:613-622.
Lack of appropriate staffing can diminish the safety and effectiveness of medical services. In this systematic review, researchers found that increased hospital staffing was generally associated with decreased rates of health care–associated infections.
Ma C, Park SH, Shang J. Int J Nurs Stud. 2018;85:1-6.
Teamwork training interventions enhance both clinical outcomes and safety culture. This cross-sectional survey found hospital units that nurses rated as more collaborative had lower rates of both hospital-acquired pressure ulcers and falls. A PSNet Interview discusses how the nursing work environment affects 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.
Ramani S, Könings KD, Mann K, et al. Acad Med. 2018;93:1348-1358.
Constructive feedback is a pillar of strong safety culture. Through resident and attending physicians focus groups at a single institution, investigators found that cultural emphasis on politeness and excellence hindered all parties' ability to provide honest feedback. The authors advocate for transitioning to a culture of growth, which would shift their institution toward a more just culture.
Weiner SG, Price CN, Atalay AJ, et al. Jt Comm J Qual Patient Saf. 2019;45:3-13.
Multidisciplinary organizational efforts are necessary to reduce inappropriate prescribing of opioids. This commentary describes the design and implementation of an opioid stewardship program that combined the use of technology, education, and clinical strategies under strong leadership guidance as a cross-disciplinary strategy to address opioid misuse.
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.
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.
Ratwani RM, Savage E, Will A, et al. J Am Med Inform Assoc. 2018;25:1197-1201.
In this simulation study, emergency department physicians completed standardized tasks using actual electronic health records (EHRs) at four sites. Even though two sites used Epic and two used Cerner EHRs, the number of clicks per task, time to task completion, and error rates varied widely. The authors highlight the importance of local implementation decisions as well as design and development in supporting usability and safety of electronic health records.

Ibrahim M; Gyuchan S; Jun GT; Robinson S. Safety Sci. 2018;106:104-120.

This literature review examined the application of system dynamics, a simulation method that incorporates qualitative and quantitative data to characterize and predict how complex systems will perform over time, to patient safety. The authors applied a human factors framework to this literature and identified several influences on safety, including supervision, external factors, and organizational culture. The authors conclude that the field of system dynamics can be applied to health care in order to improve patient safety.
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.