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psnet.ahrq.gov/node/44709/psn-pdf
November 18, 2016 - Lost information during the handover of critically injured
trauma patients: a mixed-methods study.
November 18, 2016
Zakrison TL, Rosenbloom B, McFarlan A, et al. Lost information during the handover of critically injured
trauma patients: a mixed-methods study. BMJ Qual Saf. 2016;25(12):929-936. doi:10.1136/bmjqs-2…
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psnet.ahrq.gov/node/40024/psn-pdf
December 21, 2014 - Risk factors and outcomes for foreign body left during a
procedure: analysis of 413 incidents after 1,946,831
operations in children.
December 21, 2014
Camp M, Chang DC, Zhang Y, et al. Risk factors and outcomes for foreign body left during a procedure:
analysis of 413 incidents after 1 946 831 operations in child…
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psnet.ahrq.gov/node/44447/psn-pdf
September 02, 2015 - Community-, healthcare-, and hospital-acquired severe
sepsis hospitalizations in the University HealthSystem
Consortium.
September 2, 2015
Page DB, Donnelly JP, Wang HE. Community-, Healthcare-, and Hospital-Acquired Severe Sepsis
Hospitalizations in the University HealthSystem Consortium. Crit Care Med. 2015;43(9…
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psnet.ahrq.gov/node/44522/psn-pdf
June 21, 2016 - Impact of an electronic alert notification system
embedded in radiologists' workflow on closed-loop
communication of critical results: a time series analysis.
June 21, 2016
Lacson R, O'Connor SD, Sahni A, et al. Impact of an electronic alert notification system embedded in
radiologists' workflow on closed-loop com…
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psnet.ahrq.gov/node/45419/psn-pdf
June 29, 2017 - Risk-adjusted survival for adults following in-hospital
cardiac arrest by day of week and time of day:
observational cohort study.
June 29, 2017
Robinson EJ, Smith GB, Power GS, et al. Risk-adjusted survival for adults following in-hospital cardiac
arrest by day of week and time of day: observational cohort study.…
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psnet.ahrq.gov/node/44427/psn-pdf
October 13, 2015 - Problem list completeness in electronic health records: a
multi-site study and assessment of success factors.
October 13, 2015
Wright A, McCoy AB, Hickman T-TT, et al. Problem list completeness in electronic health records: A multi-
site study and assessment of success factors. Int J Med Inform. 2015;84(10):784-90.…
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psnet.ahrq.gov/node/44094/psn-pdf
November 03, 2015 - Intended and unintended effects of large-scale adverse
event disclosure: a controlled before-after analysis of five
large-scale notifications.
November 3, 2015
Wagner TH, Taylor T, Cowgill E, et al. Intended and unintended effects of large-scale adverse event
disclosure: a controlled before-after analysis of five …
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psnet.ahrq.gov/node/44571/psn-pdf
June 21, 2016 - One size fits all? Mixed methods evaluation of the impact
of 100% single-room accommodation on staff and patient
experience, safety and costs.
June 21, 2016
Maben J, Griffiths P, Penfold C, et al. One size fits all? Mixed methods evaluation of the impact of 100%
single-room accommodation on staff and patient exper…
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psnet.ahrq.gov/node/47666/psn-pdf
January 01, 2020 - A partially structured postoperative handoff protocol
improves communication in 2 mixed surgical intensive
care units: findings from the Handoffs and Transitions in
Critical Care (HATRICC) prospective cohort study.
February 6, 2019
Lane-Fall MB, Pascual JL, Peifer HG, et al. A Partially Structured Postoperative Ha…
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psnet.ahrq.gov/node/48030/psn-pdf
May 22, 2019 - A culture of openness is associated with lower mortality
rates among 137 English National Health Service acute
trusts.
May 22, 2019
Toffolutti V, Stuckler D. A Culture Of Openness Is Associated With Lower Mortality Rates Among 137
English National Health Service Acute Trusts. Health Aff (Millwood). 2019;38(5):844-…
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psnet.ahrq.gov/node/46829/psn-pdf
July 23, 2018 - Quality and variability of patient directions in electronic
prescriptions in the ambulatory care setting.
July 23, 2018
Yang Y, Ward-Charlerie S, Dhavle AA, et al. Quality and Variability of Patient Directions in Electronic
Prescriptions in the Ambulatory Care Setting. J Manag Care Spec Pharm. 2018;24(7):691-699.
…
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/2-unc-webcast-ginsberg.pdf
June 02, 2025 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Ginsberg
AHRQ’s Surveys on Patient Safety Culture™
(SOPS™) Program
Caren Ginsberg, PhD
Center for Quality Improvement and Patient Safety, AHRQ
6
AHRQ’s Core Competencies
AHRQ is a rese…
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psnet.ahrq.gov/node/43590/psn-pdf
October 08, 2014 - Disentangling quality and safety indicator data: a
longitudinal, comparative study of hand hygiene
compliance and accreditation outcomes in 96 Australian
hospitals.
October 8, 2014
Mumford V, Greenfield D, Hogden A, et al. Disentangling quality and safety indicator data: a longitudinal,
comparative study of hand …
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psnet.ahrq.gov/node/46012/psn-pdf
December 21, 2017 - Mortality risks associated with emergency admissions
during weekends and public holidays: an analysis of
electronic health records.
December 21, 2017
Walker S, Mason A, Quan P, et al. Mortality risks associated with emergency admissions during weekends
and public holidays: an analysis of electronic health records.…
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psnet.ahrq.gov/node/47752/psn-pdf
May 29, 2019 - How do nurses use early warning scoring systems to
detect and act on patient deterioration to ensure patient
safety? A scoping review.
May 29, 2019
Wood C, Chaboyer W, Carr P. How do nurses use early warning scoring systems to detect and act on
patient deterioration to ensure patient safety? A scoping review. Int …
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - Does clinical supervision of health professionals improve
patient safety? A systematic review and meta-analysis.
September 27, 2016
Snowdon DA, Hau R, Leggat SG, et al. Does clinical supervision of health professionals improve patient
safety? A systematic review and meta-analysis. Int J Qual Health Care. 2016;28(4)…
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psnet.ahrq.gov/node/42454/psn-pdf
September 09, 2013 - A perinatal care quality and safety initiative: are there
financial rewards for improved quality?
September 9, 2013
Kozhimannil KB, Sommerness SA, Rauk P, et al. A perinatal care quality and safety initiative: are there
financial rewards for improved quality? Jt Comm J Qual Patient Saf. 2013;39(8):339-48.
https://…
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psnet.ahrq.gov/node/47407/psn-pdf
January 01, 2020 - Resource-based view on safety culture's influence on
hospital performance: the moderating role of electronic
health record implementation.
September 19, 2018
Upadhyay S, Weech-Maldonado R, Lemak CH, et al. Resource-based view on safety culture’s influence on
hospital performance: The moderating role of electronic …
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psnet.ahrq.gov/node/47875/psn-pdf
July 19, 2019 - Observer-based tools for non-technical skills assessment
in simulated and real clinical environments in healthcare:
a systematic review.
July 19, 2019
Higham H, Greig PR, Rutherford J, et al. Observer-based tools for non-technical skills assessment in
simulated and real clinical environments in healthcare: a syste…
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psnet.ahrq.gov/node/44369/psn-pdf
July 16, 2018 - The impact of a computerized physician order entry
system on medical errors with antineoplastic drugs 5
years after its implementation.
July 16, 2018
Cuervo S, Sanchis R, Lopez P, et al. The impact of a computerized physician order entry system on
medical errors with antineoplastic drugs 5 years after its implemen…