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2001. Psi 13 Postoperative Sepsis Rate (pdf file)
      qualityindicators.ahrq.gov/Downloads/Modules/PSI/v2021/TechSpecs/PSI_13_Postoperative_Sepsis_Rate.pdf
      July 01, 2021 - AHRQ Quality Indicators™ (AHRQ QI™) ICD-10-CM/PCS Specification v2021 Prepared by: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services www.qualityindicators.ahrq.gov NUMERATOR DENOMINATOR Patient Safety Indicator 13 (PSI 13) Postoperative Sepsis Rate July 2021 DESCRIPTION…

2002. Impact Case Studies on the SOPS Surveys | Agency for Healthcare Research and Quality
      www.ahrq.gov/sops/resources/case-studies.html
      March 01, 2025 - Impact Case Studies on the SOPS Surveys AHRQ’s collection of Impact Case Studies highlights successes of organizations using AHRQ’s evidence-based tools and resources. Below are success stories from organizations that used the SOPS Surveys grouped by year the case study was published. Contact us at ImpactCas…

2003. Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). | PSNet
      psnet.ahrq.gov/issue/rating-medical-emergency-teamwork-performance-development-team-emergency-assessment-measure
      January 13, 2010 - Study Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Citation Text: Cooper S, Cant R, Porter J, et al. Rating medical emergency teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation. …

2004. Crew resource management training--clinicians' reactions and attitudes. | PSNet
      psnet.ahrq.gov/issue/crew-resource-management-training-clinicians-reactions-and-attitudes
      November 16, 2022 - Study Crew resource management training--clinicians' reactions and attitudes. Citation Text: France DJ, Stiles RA, Gaffney FA, et al. Crew resource management training-Clinicians' reactions and attitudes. AORN J. 2006;82(2):213-224. doi:10.1016/s0001-2092(06)60313-x. Copy Citation …

2005. Intralipid medication errors in the neonatal intensive care unit. | PSNet
      psnet.ahrq.gov/issue/intralipid-medication-errors-neonatal-intensive-care-unit
      January 02, 2017 - Study Intralipid medication errors in the neonatal intensive care unit. Citation Text: Chuo J, Lambert G, Hicks RW. Intralipid medication errors in the neonatal intensive care unit. Jt Comm J Qual Patient Saf. 2007;33(2):104-11. Copy Citation Format: Google Scholar PubMed B…

2006. Promoting collaboration and transparency in patient safety. | PSNet
      psnet.ahrq.gov/issue/promoting-collaboration-and-transparency-patient-safety
      June 21, 2016 - Commentary Promoting collaboration and transparency in patient safety. Citation Text: Apold J, Daniels T, Sonneborn M. Promoting collaboration and transparency in patient safety. Jt Comm J Qual Patient Saf. 2006;32(12):672-675. Copy Citation Format: Google Scholar PubMed Bi…

2007. Assessment of adverse drug events among patients in a tertiary care medical center. | PSNet
      psnet.ahrq.gov/issue/assessment-adverse-drug-events-among-patients-tertiary-care-medical-center
      September 28, 2005 - Study Assessment of adverse drug events among patients in a tertiary care medical center. Citation Text: Johnston PE, France DJ, Byrne DW, et al. Assessment of adverse drug events among patients in a tertiary care medical center. Am J Health Syst Pharm. 2006;63(22):2218-27. Copy Cita…

2008. Incorporating quality and safety values into a CLABSI simulation experience. | PSNet
      psnet.ahrq.gov/issue/incorporating-quality-and-safety-values-clabsi-simulation-experience
      February 14, 2017 - Commentary Incorporating quality and safety values into a CLABSI simulation experience. Citation Text: Liebrecht CM, Lieb MC. Incorporating Quality and Safety Values into a CLABSI Simulation Experience. Nurs Forum. 2017;52(2):118-123. doi:10.1111/nuf.12175. Copy Citation Format: …

2009. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. | PSNet
      psnet.ahrq.gov/issue/twenty-four-hour-intensivist-staffing-teaching-hospitals-tensions-between-safety-today-and
      June 10, 2013 - Commentary Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Citation Text: Kerlin MP, Halpern S. Twenty-four-hour intensivist staffing in teaching hospitals: tensions between safety today and safety tomorrow. Chest. 2012;1…

2010. Addressing patient safety in rapid response activations for nonhospitalized persons. | PSNet
      psnet.ahrq.gov/issue/addressing-patient-safety-rapid-response-activations-nonhospitalized-persons
      June 18, 2014 - Study Addressing patient safety in rapid response activations for nonhospitalized persons. Citation Text: Lakshminarayana PH, Darby JM, Simmons RL. Addressing Patient Safety in Rapid Response Activations for Nonhospitalized Persons. J Patient Saf. 2017;13(1):14-19. doi:10.1097/PTS.000000…

2011. JCAHO views medication reconciliation as adverse-event prevention. | PSNet
      psnet.ahrq.gov/issue/jcaho-views-medication-reconciliation-adverse-event-prevention
      March 06, 2013 - Newspaper/Magazine Article JCAHO views medication reconciliation as adverse-event prevention. Citation Text: Thompson CA. JCAHO views medication reconciliation as adverse-event prevention. American journal of health-system pharmacy : AJHP : official journal of the American Society of H…

2012. Interprofessional communication and medical error: a reframing of research questions and approaches. | PSNet
      psnet.ahrq.gov/issue/interprofessional-communication-and-medical-error-reframing-research-questions-and-approaches
      December 08, 2010 - Review Interprofessional communication and medical error: a reframing of research questions and approaches. Citation Text: Varpio L, Hall P, Lingard LA, et al. Interprofessional communication and medical error: a reframing of research questions and approaches. Acad Med. 2008;83(10 Supp…

2013. Family-identified barriers to medication reconciliation. | PSNet
      psnet.ahrq.gov/issue/family-identified-barriers-medication-reconciliation
      September 01, 2018 - Study Family-identified barriers to medication reconciliation. Citation Text: Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs. 2009;14(2):94-101. doi:10.1111/j.1744-6155.2009.00182.x. Copy Citation Format: DOI Google Scholar Pub…

2014. Drug selection errors in relation to medication labels: a simulation study. | PSNet
      psnet.ahrq.gov/issue/drug-selection-errors-relation-medication-labels-simulation-study
      January 14, 2009 - Study Drug selection errors in relation to medication labels: a simulation study. Citation Text: Garnerin P, Perneger T, Chopard P, et al. Drug selection errors in relation to medication labels: a simulation study. Anaesthesia. 2007;62(11):1090-4. Copy Citation Format: Go…

2015. Nil per os orders for imaging: a teachable moment. | PSNet
      psnet.ahrq.gov/issue/nil-os-orders-imaging-teachable-moment
      November 13, 2024 - Commentary Nil per os orders for imaging: a teachable moment. Citation Text: Wickerham AL, Schultz EJ, Lewine EB. Nil per Os Orders for Imaging: A Teachable Moment. JAMA Intern Med. 2017;177(11):1670-1671. doi:10.1001/jamainternmed.2017.3943. Copy Citation Format: DOI Googl…

2016. Assessment of latent factors contributing to error: addressing surgical pathology error wisely. | PSNet
      psnet.ahrq.gov/issue/assessment-latent-factors-contributing-error-addressing-surgical-pathology-error-wisely
      September 01, 2012 - Study Assessment of latent factors contributing to error: addressing surgical pathology error wisely. Citation Text: Smith ML, Raab SS. Assessment of Latent Factors Contributing to Error: Addressing Surgical Pathology Error Wisely. Arch Pathol Lab Med. 2011;135(11). doi:10.5858/arpa.2011…

2017. Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. | PSNet
      psnet.ahrq.gov/issue/knowledge-based-errors-anesthesia-paired-controlled-trial-learning-and-retention
      December 06, 2023 - Study Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. Citation Text: Goldhaber-Fiebert SN, Goldhaber-Fiebert JD, Rosow CE. Knowledge-based errors in anesthesia: a paired, controlled trial of learning and retention. Can J Anaesth. 2009;56(1):3…

2018. Understanding safer practices in health care: a prologue for the role of indicators. | PSNet
      psnet.ahrq.gov/issue/understanding-safer-practices-health-care-prologue-role-indicators
      May 07, 2008 - Study Understanding safer practices in health care: a prologue for the role of indicators. Citation Text: Kazandjian VA, Wicker K, Ogunbo S, et al. Understanding safer practices in health care: a prologue for the role of indicators. J Eval Clin Pract. 2005;11(2):161-70. Copy Citation …

2019. The role of documents and documentation in communication failure across the perioperative pathway. A literature review. | PSNet
      psnet.ahrq.gov/issue/role-documents-and-documentation-communication-failure-across-perioperative-pathway
      November 06, 2015 - Review The role of documents and documentation in communication failure across the perioperative pathway. A literature review. Citation Text: Braaf S, Manias E, Riley R. The role of documents and documentation in communication failure across the perioperative pathway. A literature revi…

2020. Surgical ward round quality and impact on variable patient outcomes. | PSNet
      psnet.ahrq.gov/issue/surgical-ward-round-quality-and-impact-variable-patient-outcomes
      June 17, 2015 - Study Surgical ward round quality and impact on variable patient outcomes. Citation Text: Pucher PH, Aggarwal R, Darzi A. Surgical ward round quality and impact on variable patient outcomes. Ann Surg. 2014;259(2):222-6. doi:10.1097/SLA.0000000000000376. Copy Citation Format: …