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psnet.ahrq.gov/issue/role-radio-frequency-detection-system-embedded-surgical-sponges-preventing-retained-surgical
February 13, 2008 - Study
The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.
Citation Text:
Inaba K, Okoye O, Aksoy H, et al. The Role of Radio Frequency Detection System Embedded …
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psnet.ahrq.gov/issue/patient-engagement-surgical-site-infection-prevention-expert-panel-perspective
June 03, 2020 - Review
Patient engagement with surgical site infection prevention: an expert panel perspective.
Citation Text:
Tartari E, Weterings V, Gastmeier P, et al. Patient engagement with surgical site infection prevention: an expert panel perspective. Antimicrob Resist Infect Control. 2017;6:45.…
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psnet.ahrq.gov/issue/association-hospital-participation-surgical-outcomes-monitoring-program-inpatient
August 20, 2018 - Study
Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality.
Citation Text:
Etzioni DA, Wasif N, Dueck AC, et al. Association of hospital participation in a surgical outcomes monitoring program with inpatient complicati…
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psnet.ahrq.gov/issue/defining-optimal-length-opioid-pain-medication-prescription-after-common-surgical-procedures
August 15, 2018 - Study
Defining optimal length of opioid pain medication prescription after common surgical procedures.
Citation Text:
Scully RE, Schoenfeld AJ, Jiang W, et al. Defining Optimal Length of Opioid Pain Medication Prescription After Common Surgical Procedures. JAMA Surg. 2018;153(1):37-43. d…
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psnet.ahrq.gov/issue/analysis-adverse-events-pediatric-surgery-using-criteria-validated-adult-population
May 06, 2009 - Study
Analysis of adverse events in pediatric surgery using criteria validated from the adult population: justifying the need for pediatric-focused outcome measures.
Citation Text:
Rice-Townsend S, Hall M, Jenkins KJ, et al. Analysis of adverse events in pediatric surgery using criteri…
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psnet.ahrq.gov/issue/educational-targets-reduce-medication-errors-general-surgery-residents
October 19, 2022 - Study
Educational targets to reduce medication errors by general surgery residents.
Citation Text:
Chaitoff A, Strong AT, Bauer SR, et al. Educational Targets to Reduce Medication Errors by General Surgery Residents. J Surg Educ. 2019;76(6):1612-1621. doi:10.1016/j.jsurg.2019.04.009.
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psnet.ahrq.gov/issue/managing-competing-organizational-priorities-clinical-handover-across-organizational
February 07, 2024 - Study
Managing competing organizational priorities in clinical handover across organizational boundaries.
Citation Text:
Sujan MA, Chessum P, Rudd M, et al. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy. 2015;…
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psnet.ahrq.gov/issue/factor-structure-and-construct-validity-hospital-survey-patient-safety-culture-using
June 29, 2022 - Study
Factor structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis.
Citation Text:
Falcone ML, Tokac U, Fish AF, et al. Factor structure and construct validity of a hospital survey on patient safety culture using exploratory fac…
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psnet.ahrq.gov/issue/effect-us-drug-enforcement-administrations-rescheduling-hydrocodone-combination-analgesic
August 04, 2021 - Study
Effect of US Drug Enforcement Administration's rescheduling of hydrocodone combination analgesic products on opioid analgesic prescribing.
Citation Text:
Jones CM, Lurie PG, Throckmorton DC. Effect of US Drug Enforcement Administration's Rescheduling of Hydrocodone Combination Anal…
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psnet.ahrq.gov/issue/impact-attending-physician-workload-patient-care-survey-hospitalists
November 26, 2014 - Study
Impact of attending physician workload on patient care: a survey of hospitalists.
Citation Text:
Michtalik HJ, Yeh H-C, Pronovost P, et al. Impact of attending physician workload on patient care: a survey of hospitalists. JAMA Intern Med. 2013;173(5):375-7. doi:10.1001/jamainternme…
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psnet.ahrq.gov/issue/impact-percentage-overlapping-surgery-patient-outcomes-retrospective-cohort-study-87000
February 22, 2019 - Review
Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 87,000 surgical cases.
Citation Text:
Pitts CC, Ponce BA, Arguello AM, et al. Impact of the percentage of overlapping surgery on patient outcomes: a retrospective cohort study of 8…
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www.ahrq.gov/news/newsroom/case-studies/201520.html
July 01, 2015 - Wisconsin Critical Access Hospital Sees Big Results with AHRQ’s CUSP, RED and TeamSTEPPS®
Search All Impact Case Studies
July 2015
Amery Hospital & Clinic, a 25-bed acute care critical access hospital in rural Wisconsin, used AHRQ’s Comprehensive Unit-based Safety Program (CUSP) to reduce surgical site in…
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psnet.ahrq.gov/issue/impact-reduction-working-hours-doctors-training-postgraduate-medical-education-and-patients
November 10, 2010 - Review
Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review.
Citation Text:
Moonesinghe SR, Lowery J, Shahi N, et al. Impact of reduction in working hours for doctors in training on postgraduate medical…
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psnet.ahrq.gov/issue/executive-summary-american-college-obstetricians-and-gynecologists-presidential-task-force
September 23, 2020 - Commentary
Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.
Citation Text:
Erickson TB, Kirkpatrick DH, DeFrancesco MS, et al. Executi…
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psnet.ahrq.gov/issue/gender-power-and-leadership-effect-superiors-gender-respiratory-therapists-ability-challenge
December 02, 2015 - Study
Gender, power and leadership: the effect of a superior's gender on respiratory therapists' ability to challenge leadership during a life-threatening emergency.
Citation Text:
Pattni N, Bould MD, Hayter MA, et al. Gender, power and leadership: the effect of a superior's gender on re…
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psnet.ahrq.gov/issue/need-surgical-safety-checklists-neurosurgery-now-and-future-systematic-review
March 18, 2011 - Review
The need for surgical safety checklists in neurosurgery now and in the future - a systematic review.
Citation Text:
Westman M, Takala R, Rahi M, et al. The Need for Surgical Safety Checklists in Neurosurgery Now and in the Future-A Systematic Review. World Neurosurg. 2019. doi:10.…
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psnet.ahrq.gov/issue/errors-after-hours-phone-consultations-simulation-study
March 21, 2017 - Study
Errors in after-hours phone consultations: a simulation study.
Citation Text:
Joffe E, Turley JP, Hwang KO, et al. Errors in after-hours phone consultations: a simulation study. BMJ Qual Saf. 2014;23(5):398-405. doi:10.1136/bmjqs-2013-002243.
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psnet.ahrq.gov/issue/novel-approach-increase-residents-involvement-reporting-adverse-events
September 23, 2020 - Study
A novel approach to increase residents' involvement in reporting adverse events.
Citation Text:
Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a.
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psnet.ahrq.gov/issue/implementation-standardized-tool-root-cause-analysis-selection
November 06, 2024 - Study
Implementation of a standardized tool for root cause analysis selection.
Citation Text:
Wahlstedt E, Levy BE, Scott E, et al. Implementation of a standardized tool for root cause analysis selection. J Patient Saf. 2025;21(2):101-105. doi:10.1097/pts.0000000000001291.
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psnet.ahrq.gov/issue/impact-team-performance-surgical-safety-checklist-patient-outcomes-operating-room-black-box
March 20, 2024 - Study
Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box analysis.
Citation Text:
Al Abbas AI, Meier J, Daniel W, et al. Impact of team performance on the surgical safety checklist on patient outcomes: an operating room black box …