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Showing results for "adverse events".
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1. Related Office of Inspector General (OIG) Reports | PSO
   pso.ahrq.gov/resources/oig-reports
   October 01, 2024 - AHRQ is disseminating information related to these reports to increase understanding of adverse events … Acute-care Hospitals: Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in … October 2018 (May 2022) Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries … in Two Selected Counties (December 2008) (PDF, 821 KB) Long-Term-Care Hospitals: Adverse Events in … Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries (July 2016) Adverse

2. 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 … period of unresponsiveness and blood glucose of 29 resulting in transfer to an acute-care hospital Adverse … Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries, OEI-06-

3. 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 … Report1 as Clearly Preventable or Likely Preventable, by Clinical Category Adverse Events Related … Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries, OEI-06- … Other infection-related adverse events • Meningoencephalitis with delayed recognition contributing … to patient death Adverse Events Related to Medication Bleeding associated with anticoagulants • Gastrointestinal

4. 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 - events. … ■ 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 … may handle many kinds of patient safety events.

5. 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 - regulations at 42 CFR Part 3, provide for the disclosure of information relating to patient safety events … certification and listing of PSOs, which receive this information and analyze these patient safety events … events that were not assembled or developed for reporting to a PSO or information that exists separately … events/complaints. … events as provided in 21 CFR Part 803.

6. Resources | PSO
   pso.ahrq.gov/resources
   October 01, 2024 - Related Office of Inspector General (OIG) Reports Resources related to HHS OIG reports regarding adverse … events experienced by Medicare beneficiaries in healthcare settings.  

7. 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 - Adverse Drug Events: General Medication Topics ...................................................... … events or to mitigate harm when adverse events do occur. … Incidence of adverse events and negligence in hospitalized patients. … , other surgical and anesthesia-related events, and obstetric and neonatal adverse events, with the … Adverse Drug Events: General Medication Topics Table 2.

8. Choosing a Patient Safety Organization (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/pso-brochure.pdf
   March 01, 2020 - a PSO found that the PSO’s feedback and analysis was helpful to prevent future patient safety events … that work with a PSO, 80 percent said they find the PSO’s feedback and analysis on patient safety events … have helped prevent similar future events.* * Findings from the September 23, 2019 Final Report: Patient … 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

9. 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 … essential for identifying the underlying causes of infrequent, but often tragic, adverse events. … establishing strong protections, providers may engage in more detailed discussions about the causes of adverse … healthcare providers will ultimately result in more opportunities to identify and address the causes of adverse … adverse event rates in populations reviewed that will facilitate collection of comparable performance

10. Fedregnotice-05242016 (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
    January 04, 2025 - National Academy for State Health Policy, ‘‘2014 Guide to State Adverse Event Reporting Systems’’, … Ch 114, Rules Governing the Reporting of Sentinel Events. … events that result in patient harm. … The document the provider prepares to meet its requirement about such adverse events is not PSWP. … events in order to satisfy a federal or state law obligation. 1.

11. What are "patient safety activities"? | PSO
    pso.ahrq.gov/faq/what-are-patient-safety-activities
    By addressing common, preventable adverse events, a healthcare setting can become safer, thereby enhancing

12. 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 … However, larger PSOs that handle all kinds of patient safety events may also have access to the expertise … If one of your goals is to develop insights for rare cases or sentinel events, another relevant question … common definitions and reporting formats) to facilitate the collection and reporting of patient safety events

13. About Common Formats | PSO
    pso.ahrq.gov/common-formats/about
    November 01, 2024 - Generally, the CFER can be used to report: Incidents: patient safety events that reached the patient … Near misses (or close calls): patient safety events that did not reach the patient. … descriptions used in retrospective review of medical records to identify whether certain patient safety events … The term "surveillance" in this context refers to the improved detection of events and calculation of … adverse event rates in populations reviewed that will facilitate collection of comparable performance

14. PSO General Information
    pso.ahrq.gov/taxonomy/term/2/feed
    April 23, 2019 - By addressing common, preventable adverse events, a healthcare setting can become safer, thereby enhancing

15. 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 - in the past 12 months, and about respondent perceptions of the frequency of events reported. … Watson Senior Vice President Michigan Health & Hospital Association 3 of adverse events and discussion … offers a way for PSO members to share accounts of patient safety events. … The alerts describe the reported events and provide information on how to prevent similar events. … Exploring relationships between hospital patient safety culture and adverse events.

16. 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 - PSOs help health care professionals learn from data on patient safety events to prevent them from happening … locally, regionally, and nationally to develop insights into the underlying causes of patient safety events … PSO Privacy Protection Center) ■ Expertise to understand and prevent the causes of patient safety events … Some PSOs specialize by topic area, such as anesthesia or medication adverse PATIENT SAFETY Choosing … , while other PSOs may handle all kinds of patient safety events.

17. 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 … These initial analyses focused on events classified as Health Information Technology (HIT)- related events … Using these two approaches, nearly 102,000 reported events – among more than 4.5 million events reported

18. Other Educational Materials | PSO
    pso.ahrq.gov/resources/educational-tools
    August 01, 2022 - hospitals during COVID-19 A demonstration of how PSO participation can save hospitals money and avert adverse … events November 5, 2020 Webinar (1 hour, 2 minutes) Working With Patient Safety Organizations

19. Webinar on Working With Patient Safety Organizations (PSOs): The Value for Hospitals During COVID-19 and Beyond | PSO
    pso.ahrq.gov/about/webinar-nov5
    November 01, 2020 - hospitals during COVID-19 A demonstration of how PSO participation can save hospitals money and avert adverse … events. … demonstration of how PSO participation impacts hospitals' quality and safety performance over time, including events

20. 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 … the NPSD is to facilitate aggregation and analyses of patient safety event information to help reduce adverse … events and improve healthcare quality.