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psnet.ahrq.gov/node/42802/psn-pdf
January 07, 2015 - Patient engagement in the inpatient setting: a systematic
review.
January 7, 2015
Prey JE, Woollen J, Wilcox L, et al. Patient engagement in the inpatient setting: a systematic review. J Am
Med Inform Assoc. 2014;21(4):742-750. doi:10.1136/amiajnl-2013-002141.
https://psnet.ahrq.gov/issue/patient-engagement-inpati…
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psnet.ahrq.gov/node/866954/psn-pdf
October 16, 2024 - Patient and public involvement in healthcare: a
systematic mapping review of systematic reviews -
identification of current research and possible directions
for future research.
October 16, 2024
Bergholtz J, Wolf A, Crine V, et al. Patient and public involvement in healthcare: a systematic mapping
review of syste…
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psnet.ahrq.gov/node/47225/psn-pdf
November 02, 2018 - Preventable adverse drug events among inpatients: a
systematic review.
November 2, 2018
Gates PJ, Meyerson SA, Baysari M, et al. Preventable Adverse Drug Events Among Inpatients: A
Systematic Review. Pediatrics. 2018;142(3):e20180805. doi:10.1542/peds.2018-0805.
https://psnet.ahrq.gov/issue/preventable-adverse-dru…
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psnet.ahrq.gov/node/37130/psn-pdf
March 24, 2011 - Preventing medication errors in long-term care: results
and evaluation of a large scale web-based error reporting
system.
March 24, 2011
Pierson S, Hansen RA, Greene SB, et al. Preventing medication errors in long-term care: results and
evaluation of a large scale web-based error reporting system. Qual Saf Health …
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psnet.ahrq.gov/node/860715/psn-pdf
January 17, 2024 - Development of prescribing indicators related to opioid-
related harm in patients with chronic pain in primary care-
a modified e-Delphi study.
January 17, 2024
Bansal N, Campbell SM, Lin C-Y, et al. Development of prescribing indicators related to opioid-related
harm in patients with chronic pain in primary care—…
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psnet.ahrq.gov/node/43593/psn-pdf
May 06, 2015 - Reducing the Risks of Wrong-Site Surgery: Safety
Practices from The Joint Commission Center for
Transforming Healthcare Project.
May 6, 2015
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint
Commission Center for Transforming Healthcare; 2014.
https://psnet.ahrq.gov/issu…
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psnet.ahrq.gov/node/36577/psn-pdf
January 12, 2011 - Effects of teamwork training on adverse outcomes and
process of care in labor and delivery: a randomized
controlled trial.
January 12, 2011
Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of
care in labor and delivery: a randomized controlled trial. Obstet Gyneco…
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www.ahrq.gov/hai/cusp/toolkit/board-checklist.html
December 01, 2012 - Board Checklist
CUSP Toolkit
Who should use this tool? Senior leaders.
Checklist items
Leader Responsible
Date Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.
2. Improve the safety and teamwork climate using valid measures.
…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/boardchecklist.doc
June 02, 2025 - Checklist Items
Leader Responsible
Date
Initiated
1. Set an organization aim of annually assessing the safety and teamwork climate.
2. Improve the safety and teamwork climate using valid measures.
3. Set expectation for unit-level culture assessment.
4. Require at least a 60 percent participation…
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psnet.ahrq.gov/node/47098/psn-pdf
August 15, 2018 - Accuracy of pediatric trauma field triage: a systematic
review.
August 15, 2018
van der Sluijs R, van Rein EAJ, Wijnand JGJ, et al. Accuracy of Pediatric Trauma Field Triage: A
Systematic Review. JAMA Surg. 2018;153(7):671-676. doi:10.1001/jamasurg.2018.1050.
https://psnet.ahrq.gov/issue/accuracy-pediatric-trauma-…
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psnet.ahrq.gov/node/40776/psn-pdf
September 14, 2011 - Nursing Home Survey on Patient Safety Culture: 2011
User Comparative Database Report.
September 14, 2011
Sorra J, Famolaro T, Dyer N, Khanna K, Nelson D. Rockville, MD: Agency for Healthcare Research and
Quality; August 2011. AHRQ Publication No. 11-0071.
https://psnet.ahrq.gov/issue/nursing-home-survey-patient-sa…
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psnet.ahrq.gov/node/846444/psn-pdf
March 22, 2023 - Teamwork is associated with reduced hospital staff
burnout at military treatment facilities: findings from the
2019 Department of Defense Patient Safety Culture
Survey.
March 22, 2023
Godby Vail S, Dierst-Davies R, Kogut D, et al. Teamwork is associated with reduced hospital staff burnout
at military treatment fa…
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psnet.ahrq.gov/node/44497/psn-pdf
September 09, 2015 - VA Health Care: Actions Needed to Assess Decrease in
Root Cause Analyses of Adverse Events.
September 9, 2015
Washington, DC: United States Government Accountability Office; July 29, 2015. Publication GAO-15-643.
https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-
advers…
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psnet.ahrq.gov/node/40250/psn-pdf
July 09, 2012 - Patient involvement in patient safety: how willing are
patients to participate?
July 9, 2012
Davis R, Sevdalis N, Vincent C. Patient involvement in patient safety: How willing are patients to
participate? BMJ Qual Saf. 2011;20(1):108-114. doi:10.1136/bmjqs.2010.041871.
https://psnet.ahrq.gov/issue/patient-involvem…
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psnet.ahrq.gov/node/39402/psn-pdf
August 08, 2010 - The quest to eliminate intrathecal vincristine errors: a 40-
year journey.
August 8, 2010
Noble DJ, Donaldson LJ. The quest to eliminate intrathecal vincristine errors: a 40-year journey. Qual Saf
Health Care. 2010;19(4):323-326. doi:10.1136/qshc.2008.030874.
https://psnet.ahrq.gov/issue/quest-eliminate-intratheca…
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psnet.ahrq.gov/node/50711/psn-pdf
January 01, 2020 - Unscheduled return visits to the emergency department
with ICU admission: a trigger tool for diagnostic error.
December 4, 2019
Aaronson E, Jansson P, Wittbold K, et al. Unscheduled return visits to the emergency department with ICU
admission: A trigger tool for diagnostic error. Am J Emerg Med. 2020;38(8):1584-158…
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psnet.ahrq.gov/node/851351/psn-pdf
July 12, 2023 - Healthcare workers' experiences of patient safety in the
intensive care unit during the COVID-19 pandemic: a
multicentre qualitative study.
July 12, 2023
Berggren K, Ekstedt M, Joelsson?Alm E, et al. Healthcare workers' experiences of patient safety in the
intensive care unit during the COVID?19 pandemic: a multic…
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psnet.ahrq.gov/node/37453/psn-pdf
March 03, 2011 - Managing the prevention of retained surgical instruments:
what is the value of counting?
March 3, 2011
Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what
is the value of counting? Ann Surg. 2008;247(1):13-8.
https://psnet.ahrq.gov/issue/managing-prevention-ret…
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psnet.ahrq.gov/node/42835/psn-pdf
April 21, 2015 - Hospital board oversight of quality and patient safety: a
narrative review and synthesis of recent empirical
research.
April 21, 2015
Millar R, Mannion R, Freeman T, et al. Hospital board oversight of quality and patient safety: a narrative
review and synthesis of recent empirical research. Milbank Q. 2013;91(4):7…
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psnet.ahrq.gov/node/45891/psn-pdf
October 11, 2017 - Extent of diagnostic agreement among medical referrals.
October 11, 2017
Van Such M, Lohr R, Beckman T, et al. Extent of diagnostic agreement among medical referrals. J Eval
Clin Pract. 2017;23(4):870-874. doi:10.1111/jep.12747.
https://psnet.ahrq.gov/issue/extent-diagnostic-agreement-among-medical-referrals
Diagn…