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psnet.ahrq.gov/issue/shortage-perioperative-drugs-implications-anesthesia-practice-and-patient-safety
April 11, 2018 - Commentary
Shortage of perioperative drugs: implications for anesthesia practice and patient safety.
Citation Text:
De Oliveira GS, Theilken LS, McCarthy R. Shortage of perioperative drugs: implications for anesthesia practice and patient safety. Anesth Analg. 2011;113(6):1429-35. doi:10…
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psnet.ahrq.gov/issue/scale-nature-preventability-and-causes-adverse-events-hospitalised-older-patients
July 26, 2011 - Study
Scale, nature, preventability and causes of adverse events in hospitalised older patients.
Citation Text:
Merten H, Zegers M, de Bruijne M, et al. Scale, nature, preventability and causes of adverse events in hospitalised older patients. Age Ageing. 2013;42(1):87-93. doi:10.1093/…
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psnet.ahrq.gov/issue/aligning-patient-safety-and-stewardship-harm-reduction-strategy-children
February 27, 2019 - Review
Aligning patient safety and stewardship: a harm reduction strategy for children.
Citation Text:
Schefft M, Noda A, Godbout E. Aligning patient safety and stewardship: a harm reduction strategy for children. Curr Treat Options Pediatr. 2021;7(3):138-151. doi:10.1007/s40746-021-0022…
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psnet.ahrq.gov/issue/comparison-effects-different-typographical-methods-recognizability-printed-drug-names
May 31, 2011 - Study
A comparison of the effects of different typographical methods on the recognizability of printed drug names.
Citation Text:
Or CKL, Wang H. A comparison of the effects of different typographical methods on the recognizability of printed drug names. Drug Saf. 2014;37(5):351-9. doi:1…
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psnet.ahrq.gov/issue/patient-risk-factors-medical-injury-case-control-study
April 12, 2011 - Study
Patient risk factors for medical injury: a case–control study.
Citation Text:
Marbella AM, Laud PW, Brasel KJ, et al. Patient risk factors for medical injury: a case-control study. BMJ Qual Saf. 2011;20(2):187-93. doi:10.1136/bmjqs.2009.032664.
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…
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psnet.ahrq.gov/issue/controlled-trial-smart-infusion-pumps-improve-medication-safety-critically-ill-patients
March 13, 2019 - Study
Classic
A controlled trial of smart infusion pumps to improve medication safety in critically ill patients.
Citation Text:
Rothschild JM, Keohane C, Cook F, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill …
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psnet.ahrq.gov/issue/failure-medication-delivery-system-how-disclosure-and-systems-investigation-improve-patient
April 03, 2005 - Commentary
A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.
Citation Text:
Lucas SR, Pollak E, Makowski C. A failure in the medication delivery system—how disclosure and systems investigation improve patient safety. J Healthc Ri…
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psnet.ahrq.gov/issue/seips-101-and-seven-simple-seips-tools
October 03, 2013 - Commentary
SEIPS 101 and seven simple SEIPS tools.
Citation Text:
Holden RJ, Carayon P. SEIPS 101 and seven simple SEIPS tools. BMJ Qual Saf. 2021;30(11):901-910. doi:10.1136/bmjqs-2020-012538.
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Format:
DOI Google Scholar BibTeX EndNote X3 XML EndNote 7 XML End…
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psnet.ahrq.gov/issue/using-artificial-intelligence-improve-primary-care-patients-and-clinicians
March 02, 2022 - Commentary
Using artificial intelligence to improve primary care for patients and clinicians.
Citation Text:
Sarkar U, Bates DW. Using artificial intelligence to improve primary care for patients and clinicians. JAMA Intern Med. 2024;184(4):343-344. doi:10.1001/jamainternmed.2023.7965.
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psnet.ahrq.gov/issue/measuring-communication-surgical-icu-better-communication-equals-better-care
April 03, 2005 - Study
Measuring communication in the surgical ICU: better communication equals better care.
Citation Text:
Williams M, Hevelone N, Alban RF, et al. Measuring communication in the surgical ICU: better communication equals better care. J Am Coll Surg. 2010;210(1):17-22. doi:10.1016/j.jamc…
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/037-ss-bed-bathing-chg-cloths-protocol.docx
April 01, 2025 - AHRQ Safety Program for MRSA Prevention: Targeting SSI
Pre-Op Surgical Decolonization Protocol for Staff: Bathing With 2 Percent Chlorhexidine No-Rinse Cloths
Surgical Services
For: Cardiac, Hip and Knee Joint Replacement, and Spinal Fusion Surgeries
The following protocol details the process for performing skin decol…
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psnet.ahrq.gov/issue/postoperative-handover-problems-pitfalls-and-prevention-error
September 26, 2012 - Image/Poster
Postoperative handover: problems, pitfalls, and prevention of error.
Citation Text:
Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg. 2010;252(1):171-6. doi:10.1097/SLA.0b013e3181dc3656.
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www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/03-gray-sops-action-planning-tool.pdf
June 02, 2025 - Action Planning for the SOPS Surveys-Introducing SOPS
10
Introducing the SOPS Action
Planning Tool
Laura Gray, MPH
Senior Study Director,
User Network for the AHRQ Surveys on Patient Safety Culture
(SOPS)
Westat
11
AHRQ Surveys on Patient Safety Culture
Surveys of clinicians and staff about the extent to
w…
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psnet.ahrq.gov/issue/adverse-events-and-near-miss-reporting-nhs
August 30, 2023 - Study
Adverse events and near miss reporting in the NHS.
Citation Text:
Shaw R. Adverse events and near miss reporting in the NHS. Quality and Safety in Health Care. 2005;14(4). doi:10.1136/qshc.2004.010553.
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DOI Google Scholar BibTeX EndNote X3 XML E…
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www.ahrq.gov/sites/default/files/publications/files/system-design_0.pdf
July 01, 2011 - Designing Consumer Reporting Systems for Patient Safety Events: Project Overview
Advancing Excellence in Health Care • www.ahrq.gov
Agency for Healthcare Research and Quality PATIENT
SAFETY
Designing Consumer Reporting
Systems for Patient Safety Events
Background
It’s been nearly a decade since the Institute of
M…
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psnet.ahrq.gov/issue/sociocultural-factors-influencing-incident-reporting-among-physicians-and-nurses
May 18, 2016 - Study
Sociocultural factors influencing incident reporting among physicians and nurses: understanding frames underlying self- and peer-reporting practices.
Citation Text:
Hewitt T, Chreim S, Forster AJ. Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Und…
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www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/implementation-guide/study.html
May 01, 2017 - Appendix K. Quality Improvement Study Framework - Implementation Guide
Study Elements
Element
Definition
Things To Keep in Mind
The Purpose
Define the problem and why it is important.
Avoid suggesting causes in the purpose statement. Cause determination will come later afte…
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psnet.ahrq.gov/issue/reducing-retained-foreign-objects-operating-room-quality-improvement-initiative
April 19, 2023 - Study
Reducing retained foreign objects in the operating room: a quality improvement initiative.
Citation Text:
Keane OA, Chambers C, Brady CM, et al. Reducing retained foreign objects in the operating room: a quality improvement initiative. J Am Coll Surg. 2023;237(6):864-872. doi:10.10…
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psnet.ahrq.gov/issue/whats-psychology-got-do-it-applying-psychological-theory-understanding-failures-modern
July 10, 2017 - Commentary
"What's psychology got to do with it?" Applying psychological theory to understanding failures in modern healthcare settings.
Citation Text:
Rydon-Grange M. 'What's Psychology got to do with it?' Applying psychological theory to understanding failures in modern healthcare sett…
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meps.ahrq.gov/mepsweb/data_stats/publications.jsp
July 13, 2017 - Medical Expenditure Panel Survey Publications Search
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