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Total Results: 15 records

Showing results for "failure".

1. 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 - resulting in transfer to an acute-care hospital and contributing to death • Pneumonia and respiratory failure … treated with ineffective medication for several days, leading to increased bruising, respiratory failure … Cascade with septic shock related to urinary catheter with delayed recognition leading to respiratory failure … contributing to death • Fungal central line-associated bloodstream infection leading to acute renal failure … , requiring acute-care hospital care, and ultimately death • Altered mental status and respiratory failure

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 - associated with medication • Hyperkalemia secondary to diuretic and antihypertensive • Acute renal failure … exacerbation resulting in transfer to an acute- care hospital • Cascade event in which failure to monitor … dehydration resulting in transfer to an acute-care hospital related to poor transition of care with failure … urosepsis (characterized by increasing confusion) developed into septic shock, which led to kidney failure … harm events • Hyponatremia secondary to medication used to treat hypertension and congestive heart failure

3. PSO Printable Lists | PSO
   pso.ahrq.gov/pso/delisted/printable-list
   December 17, 2008 - Failure to Seek Continued Listing — the 3-year listing period expires without the PSO seeking continued … PSWP: February 14, 2013 12:00 am Reason for Delisting: Delisted for Cause Additional Comment: Failure … Receive PSWP: July 1, 2012 12:00 am Reason for Delisting: Delisted for Cause Additional Comment: Failure … PSWP: February 10, 2025 12:00 am Reason for Delisting: Delisted for Cause Additional Comment: Failure … Receive PSWP: July 19, 2012 12:00 am Reason for Delisting: Delisted for Cause Additional Comment: Failure

4. Delisted PSOs | PSO
   pso.ahrq.gov/pso/delisted
   Failure to Seek Continued Listing — the 3-year listing period expires without the PSO seeking continued

5. Patient Safety Organization: Two Bona Fide Contracts Requirement (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/PSO_BonaFideContracts.pdf
   September 30, 2024 - Failure to submit this form certifying compliance with the two bona fide contracts requirement by midnight

6. What Is the Role of the PSO Authorized Official? (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/what-is-the-role-of-ao.pdf
   July 01, 2021 - A PSO’s failure to timely submit these forms could result in the PSO’s delisting.

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 - Failure to Rescue ................................................................................... … Latent conditions may exist for many years before an active failure happens and triggers an accident … Among them is a preoccupation with failure. … Numerous variables (known and not yet known) can influence the success or failure of an intervention … Failure to Rescue Table 15. General Clinical Topics Table 16.

8. Patient Safety and Quality Improvement Act of 2005; Public Law 109–41, July 29, 2005 (pdf file)
   pso.ahrq.gov/sites/default/files/Patient%20Safety%20Act%20PDF.pdf
   January 01, 2025 - purposes of this subsection, an ‘adverse employment action’ includes— ‘‘(A) loss of employment, the failure … to promote an individual, or the failure to provide any other employment- related benefit for which

9. 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 - The following are examples of topics that have been discussed during Safe Table events: ■ Failure

10. Patient Safety and Quality Improvement Act of 2005; Public Law 109–41, July 29, 2005 (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/Patient-Safety-Act-2005.pdf
    January 01, 2005 - purposes of this subsection, an ‘adverse employment action’ includes— ‘‘(A) loss of employment, the failure … to promote an individual, or the failure to provide any other employment- related benefit for which

11. 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 - involved an HIT device and included a device event description (Data Element 156), device defect or failure … was most commonly reported (32.2%), with use error, combination of use error and device defect or failure

12. AHRQ Slide Template 2019-Widescreen (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
    January 01, 2020 - 53 Leading Quality and Safety “Success teaches us nothing; only failure teaches…Develop the capacity

13. PSO Common Terms and Acronyms | PSO
    pso.ahrq.gov/resources/acronyms
    August 01, 2021 - revoking its acceptance of an entity’s certification submission for listing as a PSO for the entity’s failure

14. PSO Program - Common Terms and Acronyms (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/pso-program-acronyms.pdf
    October 01, 2022 - revoking its acceptance of an entity’s certification submission for listing as a PSO for the entity’s failure

15. Patient Safety Organization (PSO) Listing Guide (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/PSO-listing-guide-2022.pdf
    January 01, 2022 - While AHRQ has the authority to delist a PSO for failure to correct a deficiency and OCR has the authority