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psnet.ahrq.gov/node/43383/psn-pdf
August 13, 2014 - Risk factors for retained surgical items: a meta-analysis
and proposed risk stratification system.
August 13, 2014
Moffatt-Bruce SD, Cook CH, Steinberg SM, et al. Risk factors for retained surgical items: a meta-analysis
and proposed risk stratification system. J Surg Res. 2014;190(2):429-36. doi:10.1016/j.jss.2014…
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psnet.ahrq.gov/node/37946/psn-pdf
June 10, 2010 - Patient comprehension of emergency department care
and instructions: are patients aware of when they do not
understand?
June 10, 2010
Engel KG, Heisler M, Smith DM, et al. Patient comprehension of emergency department care and
instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53(…
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psnet.ahrq.gov/node/42884/psn-pdf
February 06, 2014 - Application of a theoretical framework for behavior
change to hospital workers' real-time explanations for
noncompliance with hand hygiene guidelines.
February 6, 2014
Fuller C, Besser S, Savage J, et al. Application of a theoretical framework for behavior change to hospital
workers' real-time explanations for non…
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psnet.ahrq.gov/node/862602/psn-pdf
February 14, 2024 - Prevalence, contributing factors, and interventions to
reduce medication errors in outpatient and ambulatory
settings: a systematic review.
February 14, 2024
Naseralallah L, Stewart D, Price M, et al. Prevalence, contributing factors, and interventions to reduce
medication errors in outpatient and ambulatory setti…
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psnet.ahrq.gov/node/846149/psn-pdf
March 15, 2023 - Medication errors in community pharmacies: evaluation
of a standardized safety program.
March 15, 2023
Ledlie S, Gomes T, Dolovich L, et al. Medication errors in community pharmacies: evaluation of a
standardized safety program. Explor Res Clin Soc Pharm. 2023;9:100218.
doi:10.1016/j.rcsop.2022.100218.
https://ps…
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psnet.ahrq.gov/node/46428/psn-pdf
November 01, 2017 - Translating staff experience into organisational
improvement: the HEADS-UP stepped wedge, cluster
controlled, non-randomised trial.
November 1, 2017
Pannick S, Athanasiou T, Long SJ, et al. Translating staff experience into organisational improvement: the
HEADS-UP stepped wedge, cluster controlled, non-randomised …
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psnet.ahrq.gov/node/50748/psn-pdf
December 18, 2019 - Systematic review of interventions to improve safety and
quality of anticoagulant prescribing for therapeutic
indications for hospital inpatients
December 18, 2019
Frazer A, Rowland J, Mudge A, et al. Eur J Clin Pharmacol. 2019;75(12):1645-1657.
https://psnet.ahrq.gov/issue/systematic-review-interventions-imp…
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psnet.ahrq.gov/node/73976/psn-pdf
October 20, 2021 - A retrospective analysis demonstrates that a failure to
document key comorbid diseases in the anesthesia
preoperative evaluation associates with increased length
of stay and mortality.
October 20, 2021
Hofer IS, Cheng D, Grogan T. A retrospective analysis demonstrates that a failure to document key
comorbid disea…
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psnet.ahrq.gov/node/60684/psn-pdf
January 01, 2021 - Post-discharge adverse events among African American
and Caucasian patients of an urban community hospital.
July 15, 2020
Costello WG, Zhang L, Schnipper JL, et al. Post-discharge adverse events among African American and
Caucasian patients of an urban community hospital. J Racial Ethn Health Disparities. 2021;8(2)…
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psnet.ahrq.gov/node/60874/psn-pdf
September 02, 2020 - A national mixed-methods evaluation of preparedness for
general surgery residency and the association with
resident burnout.
September 2, 2020
Engelhardt KE, Bilimoria KY, Johnson JK, et al. A national mixed-methods evaluation of preparedness for
general surgery residency and the association with resident burnout.…
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psnet.ahrq.gov/node/44855/psn-pdf
July 11, 2017 - Unannounced versus announced hospital surveys: a
nationwide cluster-randomized controlled trial.
July 11, 2017
Ehlers LH, Simonsen KB, Jensen MB, et al. Unannounced versus announced hospital surveys: a
nationwide cluster-randomized controlled trial. Int J Qual Health Care. 2017;29(3):406-411.
doi:10.1093/intqhc/mz…
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psnet.ahrq.gov/node/50414/psn-pdf
September 04, 2019 - Rating the raters: an evaluation of publicly reported
hospital quality rating systems.
September 4, 2019
Bilimoria KY, Birkmeyer JD, Burstin H, et al. NEJM Catalyst. August 14, 2019.
https://psnet.ahrq.gov/issue/rating-raters-evaluation-publicly-reported-hospital-quality-rating-systems
Numerous publicly available …
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psnet.ahrq.gov/node/845347/psn-pdf
March 01, 2023 - Race differences in a malpractice event database in a
large healthcare system.
March 1, 2023
Thomas AD, Pandit C, Krevat S. Race differences in a malpractice event database in a large healthcare
system. J Patient Saf. 2023;19(2):67-70. doi:10.1097/pts.0000000000001090.
https://psnet.ahrq.gov/issue/race-differences…
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psnet.ahrq.gov/node/72643/psn-pdf
January 13, 2021 - Ockenden Report. Emerging Fndings and
Recommendations from the Independent Review of
Maternity Services at the Shrewsbury and Telford
Hospital NHS Trust.
January 13, 2021
London UK: Crown Copyright; December 10, 2020. ISBN: 9781528623049.
https://psnet.ahrq.gov/issue/ockenden-report-emerging-fndings-a…
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psnet.ahrq.gov/node/72802/psn-pdf
March 03, 2021 - What does safety in mental healthcare transitions mean
for service users and other stakeholder groups: an open-
ended questionnaire study.
March 3, 2021
Tyler N, Wright N, Panagioti M, et al. What does safety in mental healthcare transitions mean for service
users and other stakeholder groups: an open?ended questi…
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psnet.ahrq.gov/node/837332/psn-pdf
June 08, 2022 - Influence of psychological safety and organizational
support on the impact of humiliation on trainee well-
being.
June 8, 2022
Appelbaum NP, Santen SA, Perera RA, et al. Influence of psychological safety and organizational support
on the impact of humiliation on trainee well-being. J Patient Saf. 2022;18(4):370-37…
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psnet.ahrq.gov/node/46107/psn-pdf
August 16, 2017 - The relationship between patient safety climate and
occupational safety climate in healthcare—a multi-level
investigation.
August 16, 2017
Pousette A, Larsman P, Eklöf M, et al. The relationship between patient safety climate and occupational
safety climate in healthcare – A multi-level investigation. J Safety Res…
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psnet.ahrq.gov/node/38940/psn-pdf
November 25, 2009 - The role of advice in medication administration errors in
the pediatric ambulatory setting.
November 25, 2009
Lemer C, Bates DW, Yoon CS, et al. The role of advice in medication administration errors in the pediatric
ambulatory setting. J Patient Saf. 2009;5(3):168-75. doi:10.1097/PTS.0b013e3181b3a9b0.
https://psn…
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psnet.ahrq.gov/node/46939/psn-pdf
July 23, 2018 - Underdiagnosis of dementia: an observational study of
patterns in diagnosis and awareness in US older adults.
July 23, 2018
Amjad H, Roth DL, Sheehan OC, et al. Underdiagnosis of Dementia: an Observational Study of Patterns in
Diagnosis and Awareness in US Older Adults. J Gen Intern Med. 2018;33(7):1131-1138.
doi:…
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/acute/chipra-0243-section2.pdf
June 02, 2025 - Overuse of Imaging - Measure 5: Policy for ALARA Specific to Imaging Children
The percentage of facilities with a policy for “as low as reasonably achievable” (ALARA), specific to
the imaging of children. A higher proportion indicates better performance as reflected by use of
minimal radiation when imagi…