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5001. Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. | PSNet
      psnet.ahrq.gov/issue/improved-operating-room-teamwork-safety-prep-rural-community-hospitals-experience
      September 05, 2009 - Study Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. Citation Text: Paige JT, Aaron DL, Yang T, et al. Improved operating room teamwork via SAFETY prep: a rural community hospital's experience. World J Surg. 2009;33(6):1181-7. doi:10.1007/s00…

5002. Health outcomes associated with potentially inappropriate medication use in older adults. | PSNet
      psnet.ahrq.gov/issue/health-outcomes-associated-potentially-inappropriate-medication-use-older-adults
      June 29, 2011 - Study Health outcomes associated with potentially inappropriate medication use in older adults. Citation Text: Fick DM, Mion LC, Beers MH, et al. Health outcomes associated with potentially inappropriate medication use in older adults. Res Nurs Health. 2008;31(1):42-51. doi:10.1002/nur…

5003. Using the patient safety huddle as a tool for high reliability. | PSNet
      psnet.ahrq.gov/issue/using-patient-safety-huddle-tool-high-reliability
      March 01, 2023 - Commentary Using the patient safety huddle as a tool for high reliability. Citation Text: Brass SD, Olney G, Glimp R, et al. Using the Patient Safety Huddle as a Tool for High Reliability. Jt Comm J Qual Patient Saf. 2018;44(4):219-226. doi:10.1016/j.jcjq.2017.10.004. Copy Citation …

5004. Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis. | PSNet
      psnet.ahrq.gov/issue/patient-safety-vulnerabilities-children-intellectual-disability-hospital-systematic-review
      March 16, 2022 - Review Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis. Citation Text: Mimmo L, Harrison R, Hinchcliff R. Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic r…

5005. Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? | PSNet
      psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
      March 12, 2025 - Study Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? Citation Text: Suba EJ, Pfeifer JD, Raab SS. Patient identification error among prostate needle core biopsy specimens--are we ready for a DNA time-out? J Urol. 2007;178(4 Pt …

5006. Towards an understanding of the information dynamics of the handover process in aged care settings—a prerequisite for the safe and effective use of ICT. | PSNet
      psnet.ahrq.gov/issue/towards-understanding-information-dynamics-handover-process-aged-care-settings-prerequisite
      August 19, 2016 - Study Towards an understanding of the information dynamics of the handover process in aged care settings—a prerequisite for the safe and effective use of ICT. Citation Text: Lyhne S, Georgiou A, Marks A, et al. Towards an understanding of the information dynamics of the handover proces…

5007. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. | PSNet
      psnet.ahrq.gov/issue/diagnostic-errors-and-abnormal-diagnostic-tests-lost-follow-source-needless-waste-and-delay
      December 22, 2008 - Commentary Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. Citation Text: Wahls TL. Diagnostic errors and abnormal diagnostic tests lost to follow-up: a source of needless waste and delay to treatment. J Ambul Care M…

5008. Development of the barriers to error disclosure assessment tool. | PSNet
      psnet.ahrq.gov/issue/development-barriers-error-disclosure-assessment-tool
      August 28, 2019 - Study Development of the barriers to error disclosure assessment tool. Citation Text: Welsh D, Zephyr D, Pfeifle AL, et al. Development of the Barriers to Error Disclosure Assessment Tool. J Patient Saf. 2021;17(5):363-374. doi:10.1097/PTS.0000000000000331. Copy Citation Format: …

5009. Errors in the medication process: frequency, type, and potential clinical consequences. | PSNet
      psnet.ahrq.gov/issue/errors-medication-process-frequency-type-and-potential-clinical-consequences
      July 21, 2021 - Study Errors in the medication process: frequency, type, and potential clinical consequences. Citation Text: Lisby M, Nielsen LP, Mainz J. Errors in the medication process: frequency, type, and potential clinical consequences. Int J Qual Health Care. 2005;17(1):15-22. Copy Citation …

5010. Student perceptions of medical errors: incorporating an explicit professionalism curriculum in the third-year surgery clerkship. | PSNet
      psnet.ahrq.gov/issue/student-perceptions-medical-errors-incorporating-explicit-professionalism-curriculum-third
      August 04, 2021 - Study Student perceptions of medical errors: incorporating an explicit professionalism curriculum in the third-year surgery clerkship. Citation Text: Newell P, Harris S, Aufses A, et al. Student perceptions of medical errors: incorporating an explicit professionalism curriculum in the …

5011. Classification of adverse events occurring in a surgical intensive care unit. | PSNet
      psnet.ahrq.gov/issue/classification-adverse-events-occurring-surgical-intensive-care-unit
      May 01, 2013 - Study Classification of adverse events occurring in a surgical intensive care unit. Citation Text: Frankel H, Sperry J, Kaplan L, et al. Classification of adverse events occurring in a surgical intensive care unit. Am J Surg. 2007;194(3):328-32. Copy Citation Format: Goog…

5012. Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. | PSNet
      psnet.ahrq.gov/issue/anesthesia-machine-cause-intraoperative-code-red-labor-and-delivery-suite
      August 16, 2023 - Commentary Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Citation Text: Kuczkowski KM. Anesthesia machine as a cause of intraoperative "code red" in the labor and delivery suite. Arch Gynecol Obstet. 2008;278(5):477-8. doi:10.1007/s00404-008-…

5013. Patients' and healthcare workers' perceptions of a patient safety advisory. | PSNet
      psnet.ahrq.gov/issue/patients-and-healthcare-workers-perceptions-patient-safety-advisory
      March 11, 2013 - Study Patients' and healthcare workers' perceptions of a patient safety advisory. Citation Text: Schwappach DLB, Frank O, Koppenberg J, et al. Patients' and healthcare workers' perceptions of a patient safety advisory. Int J Qual Health Care. 2011;23(6):713-20. doi:10.1093/intqhc/mzr062.…

5014. Extraneous tissue a potential source for diagnostic error in surgical pathology. | PSNet
      psnet.ahrq.gov/issue/extraneous-tissue-potential-source-diagnostic-error-surgical-pathology
      October 27, 2010 - Study Extraneous tissue a potential source for diagnostic error in surgical pathology. Citation Text: Layfield LJ, Witt BL, Metzger KG, et al. Extraneous tissue: a potential source for diagnostic error in surgical pathology. Am J Clin Pathol. 2011;136(5):767-72. doi:10.1309/AJCP4FFSBPHA…

5015. Reducing medical error in the Military Health System: how can team training help? | PSNet
      psnet.ahrq.gov/issue/reducing-medical-error-military-health-system-how-can-team-training-help
      March 29, 2007 - Commentary Reducing medical error in the Military Health System: how can team training help? Citation Text: Alonso A, Baker DP, Holtzman A, et al. Reducing medical error in the Military Health System: How can team training help? Human Resource Management Review. 2006;16(3). doi:10.101…

5016. Teamwork in obstetric critical care. | PSNet
      psnet.ahrq.gov/issue/teamwork-obstetric-critical-care
      January 31, 2024 - Review Teamwork in obstetric critical care. Citation Text: Guise J-M, Segel S. Teamwork in obstetric critical care. Best Pract Res Clin Obstet Gynaecol. 2008;22(5):937-51. doi:10.1016/j.bpobgyn.2008.06.010. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNote X3…

5017. Using artificial intelligence to improve primary care for patients and clinicians. | PSNet
      psnet.ahrq.gov/issue/using-artificial-intelligence-improve-primary-care-patients-and-clinicians
      March 02, 2022 - Commentary Using artificial intelligence to improve primary care for patients and clinicians. Citation Text: Sarkar U, Bates DW. Using artificial intelligence to improve primary care for patients and clinicians. JAMA Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965. …

5018. Causes for medical errors in obstetrics and gynaecology. | PSNet
      psnet.ahrq.gov/issue/causes-medical-errors-obstetrics-and-gynaecology
      May 01, 2019 - Review Causes for medical errors in obstetrics and gynaecology. Citation Text: Klemann D, Rijkx M, Mertens H, et al. Causes for medical errors in obstetrics and gynaecology. Healthcare (Basel). 2023;11(11):1636. doi:10.3390/healthcare11111636. Copy Citation Format: DOI Go…

5019. Action Planning for the SOPS Surveys-Introducing SOPS (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
      June 02, 2025 - Action Planning for the SOPS Surveys-Introducing SOPS 10 Introducing the SOPS Action Planning Tool Laura Gray, MPH Senior Study Director, User Network for the AHRQ Surveys on Patient Safety Culture (SOPS) Westat 11 AHRQ Surveys on Patient Safety Culture Surveys of clinicians and staff about the extent to w…

5020. Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. | PSNet
      psnet.ahrq.gov/issue/evaluating-effect-distractions-operating-room-clinical-decision-making-and-patient-safety
      November 16, 2022 - Study Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. Citation Text: Murji A, Luketic L, Sobel ML, et al. Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. Surg Endosc. 2…