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psnet.ahrq.gov/node/45319/psn-pdf
September 01, 2018 - Special Issue: Progress at the Intersection of Patient
Safety and Medical Liability.
September 1, 2018
Ridgely MS, Greenberg MD, Clancy CM, eds. Health Serv Res. 2016;51(suppl 3):2395-2648.
https://psnet.ahrq.gov/issue/special-issue-progress-intersection-patient-safety-and-medical-liability
Medical liability refor…
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psnet.ahrq.gov/node/47115/psn-pdf
August 15, 2018 - Adverse events in hospitalized pediatric patients.
August 15, 2018
Stockwell DC, Landrigan CP, Toomey SL, et al. Adverse Events in Hospitalized Pediatric Patients.
Pediatrics. 2018;142(2):e20173360. doi:10.1542/peds.2017-3360.
https://psnet.ahrq.gov/issue/adverse-events-hospitalized-pediatric-patients
This study u…
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psnet.ahrq.gov/node/43547/psn-pdf
July 03, 2016 - Health care-associated infections among critically ill
children in the US, 2007-2012.
July 3, 2016
Patrick SW, Kawai AT, Kleinman K, et al. Health care-associated infections among critically ill children in
the US, 2007-2012. Pediatrics. 2014;134(4):705-712. doi:10.1542/peds.2014-0613.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/45177/psn-pdf
June 01, 2016 - Quantifying the burden of opioid medication errors in
adult oncology and palliative care settings: a systematic
review.
June 1, 2016
Heneka N, Shaw T, Rowett D, et al. Quantifying the burden of opioid medication errors in adult oncology
and palliative care settings: A systematic review. Palliat Med. 2016;30(6):520…
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psnet.ahrq.gov/node/45641/psn-pdf
October 11, 2017 - Improving health care quality and patient safety through
peer-to-peer assessment: demonstration project in two
academic medical centers.
October 11, 2017
Mort E, Bruckel J, Donelan K, et al. Improving Health Care Quality and Patient Safety Through Peer-to-
Peer Assessment: Demonstration Project in Two Academic Med…
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psnet.ahrq.gov/node/47330/psn-pdf
September 19, 2018 - Patient and consumer safety risks when using
conversational assistants for medical information: an
observational study of Siri, Alexa, and Google Assistant.
September 19, 2018
Bickmore TW, Trinh H, Olafsson S, et al. Patient and consumer safety risks when using conversational
assistants for medical information: an…
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psnet.ahrq.gov/node/45865/psn-pdf
March 15, 2017 - Exploring relationships between hospital patient safety
culture and Consumer Reports safety scores.
March 15, 2017
Smith SA, Yount N, Sorra J. Exploring relationships between hospital patient safety culture and Consumer
Reports safety scores. BMC Health Serv Res. 2017;17(1):143. doi:10.1186/s12913-017-2078-6.
http…
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psnet.ahrq.gov/node/45681/psn-pdf
January 25, 2017 - Economic evaluation of quality improvement
interventions for bloodstream infections related to central
catheters: a systematic review.
January 25, 2017
Nuckols TK, Keeler E, Morton SC, et al. Economic Evaluation of Quality Improvement Interventions for
Bloodstream Infections Related to Central Catheters: A Systema…
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psnet.ahrq.gov/node/44056/psn-pdf
May 19, 2018 - Impact of inpatient harms on hospital finances and
patient clinical outcomes.
May 19, 2018
Adler L, Yi D, Li M, et al. Impact of Inpatient Harms on Hospital Finances and Patient Clinical Outcomes. J
Patient Saf. 2018;14(2):67-73. doi:10.1097/PTS.0000000000000171.
https://psnet.ahrq.gov/issue/impact-inpatient-harms…
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psnet.ahrq.gov/node/44096/psn-pdf
November 03, 2015 - Incidence of "never events" among weekend admissions
versus weekday admissions to US hospitals: national
analysis.
November 3, 2015
Attenello FJ, Wen T, Cen SY, et al. Incidence of "never events" among weekend admissions versus
weekday admissions to US hospitals: national analysis. BMJ. 2015;350:h1460. doi:10.1136…
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psnet.ahrq.gov/node/45329/psn-pdf
April 24, 2018 - State legal restrictions and prescription-opioid use
among disabled adults.
April 24, 2018
Meara E, Horwitz JR, Powell W, et al. State Legal Restrictions and Prescription-Opioid Use among
Disabled Adults. N Engl J Med. 2016;375(1):44-53. doi:10.1056/NEJMsa1514387.
https://psnet.ahrq.gov/issue/state-legal-restricti…
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psnet.ahrq.gov/node/46203/psn-pdf
June 14, 2017 - Prescription errors related to the use of computerized
provider order-entry system for pediatric patients.
June 14, 2017
Alhanout K, Bun S-S, Retornaz K, et al. Prescription errors related to the use of computerized provider
order-entry system for pediatric patients. Int J Med Inform. 2017;103:15-19.
doi:10.1016/j…
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psnet.ahrq.gov/node/38331/psn-pdf
October 20, 2010 - Assessment of the implementation of a national patient
safety alert to reduce wrong site surgery.
October 20, 2010
Rhodes P, Giles SJ, Cook GA, et al. Assessment of the implementation of a national patient safety alert to
reduce wrong site surgery. Qual Saf Health Care. 2008;17(6):409-15. doi:10.1136/qshc.2007.0230…
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psnet.ahrq.gov/node/45210/psn-pdf
September 27, 2016 - Increased risk of burnout for physicians and nurses
involved in a patient safety incident.
September 27, 2016
Van Gerven E, Elst TV, Vandenbroeck S, et al. Increased Risk of Burnout for Physicians and Nurses
Involved in a Patient Safety Incident. Med Care. 2016;54(10):937-943.
doi:10.1097/MLR.0000000000000582.
ht…
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psnet.ahrq.gov/node/44544/psn-pdf
October 07, 2015 - Systematic review on the prevalence, frequency and
comparative value of adverse events data in social media.
October 7, 2015
Golder S, Norman G, Loke YK. Systematic review on the prevalence, frequency and comparative value of
adverse events data in social media. Br J Clin Pharmacol. 2015;80(4):878-88. doi:10.1111/b…
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psnet.ahrq.gov/node/48176/psn-pdf
July 31, 2019 - Duration of second victim symptoms in the aftermath of a
patient safety incident and association with the level of
patient harm: a cross-sectional study in the Netherlands.
July 31, 2019
Vanhaecht K, Seys D, Schouten L, et al. Duration of second victim symptoms in the aftermath of a patient
safety incident and ass…
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psnet.ahrq.gov/node/45556/psn-pdf
June 29, 2017 - Readmission rates after passage of the Hospital
Readmissions Reduction Program: a pre–post analysis.
June 29, 2017
Wasfy JH, Zigler CM, Choirat C, et al. Readmission Rates After Passage of the Hospital Readmissions
Reduction Program: A Pre-Post Analysis. Ann Intern Med. 2017;166(5):324-331. doi:10.7326/M16-0185.
h…
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psnet.ahrq.gov/node/45118/psn-pdf
January 23, 2017 - Cluster randomized trial to evaluate the impact of team
training on surgical outcomes.
January 23, 2017
Duclos A, Peix JL, Piriou V, et al. Cluster randomized trial to evaluate the impact of team training on
surgical outcomes. Br J Surg. 2016;103(13):1804-1814. doi:10.1002/bjs.10295.
https://psnet.ahrq.gov/issue/c…
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psnet.ahrq.gov/node/42548/psn-pdf
December 29, 2014 - What is known about adverse events in older medical
hospital inpatients? A systematic review of the literature.
December 29, 2014
Long SJ, Brown KF, Ames D, et al. What is known about adverse events in older medical hospital
inpatients? A systematic review of the literature. Int J Health Care Qual. 2013;25(5):542-5…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-new_sops_diagnostic_safety-ginsberg.pdf
June 02, 2025 - New AHRQ SOPS® Diagnostic Safety Supplemental Items for Medical Offices - Ginsberg
AHRQ’s Surveys on Patient Safety Culture™
(SOPS®) Program
Caren Ginsberg, Ph.D.
Center for Quality Improvement and Patient Safety, AHRQ
6
AHRQ’s SOPS Program
• Initiated and funded by AHRQ since 2001 to advance the understanding,…