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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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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.
Simsekler MCE, Ward JR, Clarkson J. Ergonomics. 2018;61:1046-1064.
In aviation and other high reliability industries, organizations prioritize proactive risk identification in addition to root cause analysis after safety events occur. Researchers developed a risk identification framework for their health system and tested its feasibility with health care workforce members.
Ford EC, Evans SB. Med Phys. 2018;45:e100-e119.
Learning from adverse events is a core component of patient safety improvement. This review explores the application of this concept in radiation oncology, successful practices, and challenges for incident learning system implementation in the specialty.
Young M, Thomas A, Lubarsky S, et al. Acad Med. 2018;93:990-995.
Enhancing clinical reasoning skill is emerging as a strategy to reduce diagnostic error. This review spotlights the need for a uniform definition of clinical reasoning and a robust literature base to augment efforts to improve reasoning and decision making. The authors suggest these refinements will identify cognitive biases and other contextual influences on clinical reasoning and improve education and professional development.
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.
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.
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.
Gandhi TK, Kaplan GS, Leape L, et al. BMJ Qual Saf. 2018;27:1019-1026.
Over the last decade, the Lucian Leape Institute has explored five key areas in health care to advance patient safety. These include medical education reform, care integration, patient and family engagement, transparency, and joy and meaning in work and workforce safety for health care professionals. This review highlights progress to date in each area and the challenges that remain to be addressed, including increasing clinician burnout and shortcomings of existing health information technology approaches. The authors also suggest opportunities for further research such as measuring the impact of residency training programs. In a past PSNet interview, Dr. Tejal Gandhi, president of the IHI/NPSF Lucian Leape Institute, discussed improving patient safety at a national level.
Zhou L; Blackley SV; Kowalski L; Doan R; Acker WW; Landman AB; Kontrient E; Mack D; Meteer M; Bates DW; Goss FR.
Clinical documentation is an essential part of patient care. However, in the electronic health record era, documentation is widely perceived to be inefficient and a significant driver of physician burnout. Speech recognition software, which directly transcribes clinicians' dictated speech, is increasingly being used in order to streamline the documentation workflow. This study examined the accuracy of speech recognition software in a sample of notes (progress notes, operative notes, and discharge summaries) produced by 144 clinicians of multiple disciplines in 2 health systems. Transcripts produced by speech recognition software had 7.4 errors per 100 transcribed words, with many of these errors being potentially clinically significant. Although review by a professional medical transcriptionist corrected most of these errors, about 1 in 300 words remained incorrect even in the final physician-signed note. This study corroborates prior research that found potentially significant error rates in software-transcribed emergency medicine and radiology notes. A WebM&M commentary discussed an adverse event that occurred due to a transcription error in a radiology study report.
Stockwell DC, Landrigan CP, Toomey SL, et al. Pediatrics. 2018;142:e20173360.
This study used a trigger tool (the Global Assessment of Pediatric Patient Safety) to examine temporal trends in adverse event rates at 16 randomly selected children's hospitals. Adverse event rates did not significantly change at either teaching or nonteaching hospitals from 2007 to 2012. Interestingly, nonteaching hospitals had lower error rates than teaching facilities, although the increased complexity of patients at teaching hospitals may account for this finding. The results of this study mirror those of a similar study conducted in adult hospitals from 2002 to 2007. An accompanying editorial notes that quality improvement collaboratives have achieved reductions in hospital-acquired conditions at children's hospitals and speculates that these discordant findings could be due to the fact that trigger tools are able to detect a broader range of adverse events and thus may provide a more accurate picture of safety. A WebM&M commentary discussed a preventable medication error at a children's hospital.
Jung JJ, Jüni P, Lebovic G, et al. Ann Surg. 2020;271:122-127.
Analysis of errors in aviation is facilitated by the cockpit "black box," which records flight data as well as communications between team members. This study reports on initial data from the OR Black Box, a novel monitoring technology that integrates continuous monitoring of intraoperative data with video and audio recording of operative procedures. In this initial study of elective laparoscopic procedures, auditory and cognitive distractions were common, and multiple safety events occurred during each procedure.
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.
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.
World Health Organization; Organisation for Economic Co-operation and Development; OECD; World Bank.
The Crossing the Quality Chasm report outlined the importance of building health care processes that ensure safe, efficient, effective, timely, equitable, and patient-centered health care practice. Spotlighting the importance of an integrated approach to achieving high-quality care, this report outlines how governments, health services, health care staff, and patients can enhance health care quality. A past PSNet interview discussed the global impact of the World Health Organization's efforts to improve patient safety.
Gomes T, Tadrous M, Mamdani MM, et al. JAMA Netw Open. 2018;1:e180217.
Opioid use can increase risk of adverse drug events, including overdoses. Researchers utilized data from the Centers for Disease Control and Prevention to examine opioid-related deaths in the United States from 2001 to 2016. During this period, opioid-related deaths increased by nearly 350%. Overdose deaths occurred more among men than women and were most prevalent in patients aged 15 to 34 years. These findings raise concern regarding the increasing proportion of deaths associated with opioid use. The authors call for targeted prevention and harm reduction efforts among young adults to address the growing opioid-related harm in this group. A PSNet perspective discussed opioid overdose as a patient safety problem.
Griffiths P, Recio-Saucedo A, Dall'Ora C, et al. J Adv Nurs. 2018;74:1474-1487.
Inadequate hospital nurse staffing is linked to increased mortality. This systematic review found that lower nurse staffing is associated with more reports of missed nursing care. Two of the authors summarized the science of missed nursing care in a recent PSNet perspective.
Larochelle MR, Bernson D, Land T, et al. Ann Intern Med. 2018;169:137-145.
Nationally, opioid overdose remains a common cause of preventable death. Treatment of opioid use disorder with opioid replacement therapy, specifically methadone or buprenorphine, is a potent but underutilized strategy for reducing opioid-related harm. Investigators employed a prospective cohort study to follow 17,568 adults who were treated in Massachusetts emergency departments for a nonfatal opioid overdose. About 15% received opioid replacement therapy in the subsequent 2 years. Patients on opioid replacement therapy were substantially less likely to die from opioids or any other cause. An accompanying editorial from leaders at the National Institute on Drug Abuse highlights strategies to increase the number of Americans offered these life-saving therapies. The editorial also notes the alarming number of patients who received prescriptions for short-acting opioids and benzodiazepines after an opioid overdose. A past Annual Perspective and PSNet perspective delineated other strategies for addressing the opioid crisis.
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.

Loh E. BMJ Leader. 2018;2(2):59-63.

Artificial intelligence (AI) can improve diagnostic accuracy. Despite early enthusiasm for the utility of AI at the front line, some have raised concerns associated with legal liabilities and ethical issues. This review discusses these considerations and suggests approaches that leaders and clinicians should embrace to prepare for future integration of AI systems in practice.