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  1. psnet.ahrq.gov/issue/achieving-perfect-handoff-patient-transfers-building-teamwork-and-trust
    October 08, 2016 - Commentary Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. Citation Text: Clarke D, Werestiuk K, Schoffner A, et al. Achieving the 'perfect handoff' in patient transfers: building teamwork and trust. J Nurs Manag. 2012;20(5):592-8. doi:10.1111/j.1365-…
  2. www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/02-sops-riverside-handoffs-webcast-bakdash.pdf
    January 01, 2022 - Improving Hospital Handoffs Using AHRQ’s Surveys on Patient Safety Culture® Hospital Survey - Bakdash AHRQ’s Surveys on Patient Safety Culture® (SOPS®) Program Jonathan Bakdash, Ph.D. Center for Quality Improvement and Patient Safety, AHRQ Agency for Healthcare Research and Quality • AHRQ is: ► A research and …
  3. psnet.ahrq.gov/issue/year-1-medical-undergraduates-knowledge-and-attitudes-medical-error
    March 24, 2011 - Study Year 1 medical undergraduates' knowledge of and attitudes to medical error. Citation Text: Flin R, Patey R, Jackson J, et al. Year 1 medical undergraduates' knowledge of and attitudes to medical error. Med Educ. 2009;43(12):1147-55. doi:10.1111/j.1365-2923.2009.03499.x. Copy Ci…
  4. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/putoolkit_module5_tools.docx
    June 02, 2025 - Pressure Ulcer Prevention Toolkit Pressure Ulcer Prevention Toolkit Module 5 Tools Action Plan Tool to Measure Pressure Ulcer Rates and Pressure Ulcer Prevention Practices Tool 5C: Assessing Comprehensive Skin Assessment Tool 5D: Assessing Standardized Risk Assessment Tool 5E: Assessing Care Planning AHRQ Pressure…
  5. psnet.ahrq.gov/issue/weaving-healthcare-tapestry-safety-and-communication
    September 29, 2017 - Commentary Weaving a healthcare tapestry of safety and communication. Citation Text: Hay J, Collin S, Koruth S. Weaving a healthcare tapestry of safety and communication. Nurs Manage. 2014;45(7):40-6. doi:10.1097/01.NUMA.0000451035.84587.7d. Copy Citation Format: DOI Google…
  6. psnet.ahrq.gov/issue/chasing-6-sigma-drawing-lessons-cockpit-culture
    April 22, 2015 - Commentary Chasing the 6-sigma: drawing lessons from the cockpit culture. Citation Text: Hickey EJ, Halvorsen F, Laussen PC, et al. Chasing the 6-sigma: Drawing lessons from the cockpit culture. J Thorac Cardiovasc Surg. 2017;155(2). doi:10.1016/j.jtcvs.2017.09.097. Copy Citation F…
  7. psnet.ahrq.gov/issue/ensuring-staff-safety-when-treating-potentially-violent-patients
    July 14, 2010 - Commentary Ensuring staff safety when treating potentially violent patients. Citation Text: Roca RP, Charen B, Boronow J. Ensuring Staff Safety When Treating Potentially Violent Patients. JAMA. 2016;316(24):2669-2670. doi:10.1001/jama.2016.18260. Copy Citation Format: DOI G…
  8. psnet.ahrq.gov/issue/my-brothers-keeper-must-physician-disclose-anothers-medical-error-and-potential-negligence
    February 01, 2023 - Commentary My brother's keeper: must a physician disclose another's medical error and potential negligence? Citation Text: Liang BA, Smith C by DS. My brother's keeper: must a physician disclose another's medical error and potential negligence? J Clin Anesth. 2007;19(7):558-562. doi:10…
  9. psnet.ahrq.gov/issue/viewpoint-patient-safety-primary-care-patients-are-not-just-beneficiary-critical-component
    August 16, 2017 - Commentary Viewpoint: Patient safety in primary care - patients are not just a beneficiary but a critical component in its achievement. Citation Text: Kavanagh KT, Cormier LE. Viewpoint: Patient safety in primary care – patients are not just a beneficiary but a critical component in its …
  10. psnet.ahrq.gov/issue/are-they-safe-there-patient-safety-and-trainees-practice
    September 22, 2021 - Commentary Are they safe in there? Patient safety and trainees in the practice. Citation Text: Byrnes PD, Crawford M, Wong B. Are they safe in there? - patient safety and trainees in the practice. Aust Fam Physician. 2012;41(1-2):26-9. Copy Citation Format: Google Scholar P…
  11. www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/NCINQTobaccoUseHelp-References.pdf
    August 01, 2012 - National Collaborative for Innovation in Quality Measurement Tobacco Use and Help List of References Campaign for Tobacco-Free Kids. 2012. Tobacco Overview. http://www.tobaccofreekids.org/facts_issues/tobacco_101/ (April 2012). Campaign for Tobacco-Free Kids. 2011. Health Harms from Smoking and Other Tobac…
  12. psnet.ahrq.gov/issue/covid-19-nursing-homes-cms-needs-continue-strengthen-oversight-infection-prevention-and
    October 26, 2022 - Book/Report COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control. Citation Text: COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control. Washington, DC: United States Government …
  13. psnet.ahrq.gov/issue/sbar-shared-mental-model-improving-communication-between-clinicians
    January 02, 2017 - Study SBAR: a shared mental model for improving communication between clinicians. Citation Text: Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-75. Copy Citation Format: …
  14. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy1/Strat1_Tool_12_WkWthAdv_HO_508.docx
    June 02, 2025 - Strategy 1: Working with Patients & Families as Advisors (Tool 12) Strategy 1: Working With Patients & Families as Advisors (Tool 12) Strategy 1: Working with Patients & Families as Advisors [Type text] [Type text] [Type text] Strategy 1: Working With Patients & Families as Advisors (Tool 12) Working With Patient an…
  15. psnet.ahrq.gov/issue/impact-checklists-inpatient-safety-outcomes-systematic-review-randomized-controlled-trials
    September 29, 2021 - Review The impact of checklists on inpatient safety outcomes: a systematic review of randomized controlled trials. Citation Text: Boyd J, Wu G, Stelfox HT. The Impact of Checklists on Inpatient Safety Outcomes: A Systematic Review of Randomized Controlled Trials. J Hosp Med. 2017;12(8):6…
  16. digital.ahrq.gov/type-care/tertiary-care
    January 01, 2023 - Tertiary Care ML-ROVER: Machine Learning to Reduce Laboratory Test Overutilization Description The study will develop, validate, implement, and assess the usability of a machine learning based clinical decision support tool designed to reduce laboratory testing overutilization…
  17. psnet.ahrq.gov/issue/utilizing-improvement-science-methods-improve-physician-compliance-proper-hand-hygiene
    April 13, 2011 - Study Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Citation Text: White CM, Statile AM, Conway PH, et al. Utilizing improvement science methods to improve physician compliance with proper hand hygiene. Pediatrics. 2012;129(4):e1042-50.…
  18. psnet.ahrq.gov/issue/leadership-initiative-improve-communication-and-enhance-safety
    March 11, 2009 - Commentary A leadership initiative to improve communication and enhance safety. Citation Text: Donahue M, Miller M, Smith L, et al. A Leadership Initiative to Improve Communication and Enhance Safety. American Journal of Medical Quality. 2011;26(3). doi:10.1177/1062860610387410. Copy…
  19. psnet.ahrq.gov/issue/role-information-technology-healthcare-communications-efficiency-and-patient-safety
    October 19, 2022 - Commentary The role of information technology in healthcare communications, efficiency, and patient safety: application and results. Citation Text: Prince SB, Herrin DM. The role of information technology in healthcare communications, efficiency, and patient safety: application and res…
  20. psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improving-safety-iv-drug-administration
    March 23, 2012 - Study Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Citation Text: Adachi W, Lodolce AE. Use of failure mode and effects analysis in improving the safety of i.v. drug administration. Am J Health Syst Pharm. 2005;62(9):917-20. Copy Citat…