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Showing results for "adverse event".
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1. Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable or Likely Preventable by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
   July 01, 2016 - Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable … or Likely Preventable by Clinical Category Page 1 of 4 Adverse and Temporary Harm Events in Rehabilitation … Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category Adverse … to congestive heart failure exacerbation resulting in transfer to an acute- care hospital • Cascade event … Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries, OEI-06-

2. About Common Formats | PSO
   pso.ahrq.gov/common-formats/about
   November 01, 2024 - AHRQ has developed Common Formats for Event Reporting for several healthcare settings and event types … What Are the Common Formats for Event Reporting (CFER)? … Unsafe conditions: circumstances that increase the probability of a patient safety event occurring. … The CFS is a set of event descriptions used in retrospective review of medical records to identify … The term "surveillance" in this context refers to the improved detection of events and calculation of adverse

3. U.S. Department of Health and Human Services Guidance Regarding Patient Safety Organizations' Reporting Obligations and the Patient Safety and Quality Improvement Act of 2005 (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/fda-guidance-pso.pdf
   December 01, 2010 - FDA-regulated entities generally have mandatory adverse event reporting responsibilities under the FDCA … event information the PSO receives as PSWP in order to fully comply with its MDR responsibilities … and its implementing regulations, device manufacturers are required to establish and maintain MDR event … Thus, FDA may inspect facilities and any adverse event/complaint files, including files containing PSWP … event files related to its products, including files containing PSWP that it creates or receives as

4. Related Office of Inspector General (OIG) Reports | PSO
   pso.ahrq.gov/resources/oig-reports
   August 01, 2025 - AHRQ is disseminating information related to these reports to increase understanding of adverse events … Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018 (May 2022) Adverse … Events in Hospitals: National Incidence Among Medicare Beneficiaries (November 2010) (PDF, 3.4 MB) Adverse … Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries (July 2016) Adverse … determined that the majority of these events could be captured using the current Common Formats for Event

5. PSO Quiz--Answer Sheet (pdf file)
   pso.ahrq.gov/sites/default/files/quiz/pso-quiz-answer-sheet.pdf
   January 01, 2020 - risk management department, the nurse prepares a written statement documenting her observations of an adverse … event to put the hospital’s professional liability insurer on notice of a potential claim. … a written statement prepared for purposes of reporting to the PSO and/or subsequent analysis of an adverse … event when conducted in the provider’s or PSO’s PSES could be PSWP.]

6. Artificial Intelligence (AI) in Healthcare Safety Program: October 2024 Update (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
   July 01, 2025 - AI has also been applied to patient safety directly, for example, to attempt to prevent major adverse … events such as healthcare- associated infections, adverse drug events, and diagnostics errors, among … • There is consensus among the PSOs that AI is currently not thought of as its own adverse event … safety event via structured data. … have informed the patient’s care, and knowledge that AI may have contributed to the event

7. Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
   January 01, 2019 - Adverse and Temporary Harm Events in Long-Term-Care Hospitals (LTCH) Designated in Office of Inspector … General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category Page 1 of 9 Adverse … of Inspector General Report1 as Clearly Preventable or Likely Preventable, by Clinical Category Adverse … on ventilator • Pneumonia with delayed recognition and treatment Sepsis not associated with other event … Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries, OEI-06-

8. Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf
   December 21, 2021 -  Patient safety event reporting is voluntary at all levels. … The dashboard charts detail event type, report type by event type, extent of harm by event type, event … to prevent the adverse event. … event reduction, control and prevention of healthcare-associated infections, and adverse drug reactions … ) MHS III (2020) Computer Adverse Drug Event (ADE) Detection and Alerts Summary of Evidence (Not

9. Fedregnotice-05242016 (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
   January 04, 2025 - event reporting systems, and Texas began implementing a system in January 2015. … National Academy for State Health Policy, ‘‘2014 Guide to State Adverse Event Reporting Systems’’, … event reports ‘‘on file at the facility for a minimum of five years.’’ … event reporting systems.3 The legal system provides another course to pursue accountability for … drug event reporting to the Food and Drug Administration (FDA), certification or licensing recordkeeping

10. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/npsdpatient-safety-culture-brief.pdf
    September 01, 2016 - One way to drive improved culture is to develop the norm of routine safety event reporting. … that encourage and facilitate patient safety Program Brief Network of Patient Safety Databases event … Watson Senior Vice President Michigan Health & Hospital Association 3 of adverse events and discussion … Several PSOs provide members a confidential analysis of patient safety event data, and provide forums … Exploring relationships between hospital patient safety culture and adverse events.

11. PSO Quiz--Question Sheet (pdf file)
    pso.ahrq.gov/sites/default/files/quiz/pso-quiz-questions.pdf
    January 01, 2020 - risk management department, the nurse prepares a written statement documenting her observations of an adverse … event to put the hospital’s professional liability insurer on notice of a potential claim.

12. Frequently Asked Questions | PSO
    pso.ahrq.gov/faq
    April 01, 2023 - By addressing common, preventable adverse events, a healthcare setting can become safer, thereby enhancing … the information about the patient safety event. … patient safety events essential for identifying the underlying causes of infrequent, but often tragic, adverse … AHRQ has developed Common Formats for Event Reporting for several healthcare settings and event types … What are the Common Formats for Event Reporting (CFER)?

13. Choosing a Patient Safety Organization: Tips for Hospitals and Health Care Providers (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/ChoosingPSO_2016.pdf
    January 01, 2016 - challenging, you must gain the trust of clinicians who may fear the results of acknowledging their role in adverse … ■ Feedback and expertise to help you understand and prevent the causes of adverse events and to develop … successful approaches to improving quality and reducing adverse outcomes. … Some PSOs specialize by topic area, such as anesthesia or medication adverse events, while other PSOs

14. PSO Common Terms and Acronyms | PSO
    pso.ahrq.gov/resources/acronyms
    August 01, 2021 - Equitable Relief – The Patient Safety Act prohibits a provider from taking an adverse employment action … Equitable relief refers to the relief that an individual may seek in a civil action to redress an adverse … Patient Safety Organizations' Reporting Obligations to the FDA  (PDF, 0.4 MB) HERF – Healthcare Event … The goal of the NPSD is to facilitate aggregation and analyses of patient safety event information to … help reduce adverse events and improve healthcare quality.

15. PSO Program - Common Terms and Acronyms (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/pso-program-acronyms.pdf
    October 01, 2022 - index.html Page 4 of 6 Equitable Relief – The Patient Safety Act prohibits a provider from taking an adverse … Equitable relief refers to the relief that an individual may seek in a civil action to redress an adverse … HERF – Healthcare Event Reporting Form (HERF); it is one of 3 general forms of AHRQ’s Common Formats. … The goal of the NPSD is to facilitate aggregation and analyses of patient safety event information to … help reduce adverse events and improve health care quality.

16. AHRQ Slide Template 2019-Widescreen (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
    January 01, 2020 - aggregate patient safety data, and to develop customized approaches to improve quality and reduce adverse … submit and receive PSWP, confidentiality and privilege, and ‘How to report to PSO (SBAR format)’: • Event … Reporting (Safety Event/Sentinel event) • Patient Safety Plan • Root Cause Analysis • Confidentiality … Press Ganey/HPI model) approx. 3500 have taken this course since 2014 • Bimonthly, anonymous Safety Event … Guidance Re: Sentinel Event Alerts, ISMP, etc. e.

17. Choosing a Patient Safety Organization (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/pso-brochure.pdf
    March 01, 2020 - PSOs can help you develop successful approaches to improving quality and reducing adverse outcomes. … Some PSOs specialize in a specific area, such as anesthesia or medication adverse events, or focus on

18. Choosing a Patient Safety Organization: Tips for Hospitals and Health Care Providers (pdf file)
    pso.ahrq.gov/sites/default/files/Choosing%20a%20PSO.pdf
    August 01, 2012 - confidentiality of deliberations and analysis of quality and safety events ■ Aggregation of patient safety event … Some PSOs specialize by topic area, such as anesthesia or medication adverse PATIENT SAFETY Choosing

19. Resources | PSO
    pso.ahrq.gov/resources
    October 01, 2024 - Related Office of Inspector General (OIG) Reports Resources related to HHS OIG reports regarding adverse

20. How To Choose a PSO | PSO
    pso.ahrq.gov/work-with/choose
    November 01, 2020 - Some PSOs specialize by topic area, such as anesthesia or medication adverse events, so you may want