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psnet.ahrq.gov/node/40231/psn-pdf
February 23, 2011 - Multiple component patient safety intervention in English
hospitals: controlled evaluation of second phase.
February 23, 2011
Benning A, Dixon-Woods M, Nwulu U, et al. Multiple component patient safety intervention in English
hospitals: controlled evaluation of second phase. BMJ. 2011;342:d199. doi:10.1136/bmj.d199…
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psnet.ahrq.gov/node/47073/psn-pdf
July 02, 2019 - Physician prescribing of opioids to patients at increased
risk of overdose from benzodiazepine use in the United
States.
July 2, 2019
Ladapo JA, Larochelle MR, Chen A, et al. Physician Prescribing of Opioids to Patients at Increased Risk of
Overdose From Benzodiazepine Use in the United States. JAMA Psychiatry. 20…
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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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psnet.ahrq.gov/node/39768/psn-pdf
August 18, 2010 - Medical team training and coaching in the veterans health
administration; assessment and impact on the first 32
facilities in the programme.
August 18, 2010
Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration;
assessment and impact on the first 32 facilities in…
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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/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/43436/psn-pdf
August 13, 2014 - Decreasing handoff-related care failures in children's
hospitals.
August 13, 2014
Bigham MT, Logsdon TR, Manicone PE, et al. Decreasing handoff-related care failures in children's
hospitals. Pediatrics. 2014;134(2):e572-e579. doi:10.1542/peds.2013-1844.
https://psnet.ahrq.gov/issue/decreasing-handoff-related-care-…
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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…
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/board-checklist.html
July 01, 2023 - Board Checklist
AHRQ Safety Program for Perinatal Care
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 c…
-
psnet.ahrq.gov/node/37499/psn-pdf
January 10, 2017 - Medicare's decision to withhold payment for hospital
errors: the devil is in the details.
January 10, 2017
Wachter R, Foster NE, Dudley A. Medicare's decision to withhold payment for hospital errors: the devil is in
the det. Jt Comm J Qual Patient Saf. 2008;34(2):116-23.
https://psnet.ahrq.gov/issue/medicares-deci…
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psnet.ahrq.gov/node/836964/psn-pdf
April 20, 2022 - Occurrence of no-harm incidents and adverse events in
hospitalized patients with ischemic stroke or TIA: a
cohort study using trigger tool methodology.
April 20, 2022
Nowak B, Schwendimann R, Lyrer P, et al. Occurrence of no-harm incidents and adverse events in
hospitalized patients with ischemic stroke or TIA: a …
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www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/chipra-89-adhd-behavior-section-2-attach-3.pdf
June 02, 2025 - Section 2: Detailed Measure Specifications, Attachment 2: EHR Recommended Data Locations
SNAC Submission Form Measure 2: ADHD Behavior Therapy
Section 2: Detailed Measure Specifications
Attachment 2: EHR Recommended Data Locations
Th…
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psnet.ahrq.gov/node/36208/psn-pdf
January 05, 2017 - Implementing computerized provider order entry with an
existing clinical information system.
January 5, 2017
Barron WM, Reed L, Forsythe S, et al. Implementing computerized provider order entry with an existing
clinical information system. Jt Comm J Qual Patient Saf. 2006;32(9):506-16.
https://psnet.ahrq.gov/issue…
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psnet.ahrq.gov/node/44433/psn-pdf
June 21, 2016 - Ambulance diversion associated with reduced access to
cardiac technology and increased one-year mortality.
June 21, 2016
Shen Y-C, Hsia RY. Ambulance diversion associated with reduced access to cardiac technology and
increased one-year mortality. Health Aff (Millwood). 2015;34(8):1273-80. doi:10.1377/hlthaff.2014.1…
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psnet.ahrq.gov/node/45037/psn-pdf
February 15, 2017 - Disclosing large scale adverse events in the US Veterans
Health Administration: lessons from media responses.
February 15, 2017
Maguire EM, Bokhour BG, Asch SM, et al. Disclosing large scale adverse events in the US Veterans
Health Administration: lessons from media responses. Public Health. 2016;135:75-82.
doi:10…