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Showing results for "fall".
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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 - changes in mental status • Cascade with oversedation while on multiple opioid medications leading to a fall … patient resulting in desaturation, hypoxemia, replacement of the tube, and aspiration pneumonia Fall … with injury • Fall with recurrent right hip fracture associated with inadequate monitoring Page 5 … from gastric secretions due to PEG leak • Skin tear and abrasion on sacral area • Skin tear forearm Fall … with injury • Fall with laceration forehead • Fall with soft tissue hematoma over left maxillary sinus

2. Network of Patient Safety Databases (NPSD) Data Spotlights | PSO
   pso.ahrq.gov/common-formats/npsd-data-spotlights
   November 01, 2024 - Emergency (PDF, 4.6 MB) Falls: Falls: Associated Factors and Clinical Outcomes (PDF, 4.7 MB) Patterns of Fall

3. 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 - Additional NPSD data tools include annual Chartbooks, with a focus on fall events in 202311 and medication … For example, a key finding of the most recent Spotlight, on Patterns of Fall Interventions,13 is that … were in place among patients with different risks for falls, suggesting a less tailored approach to fall … 2024.pdf 13 https://www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf … consensus among the PSOs that AI is currently not thought of as its own adverse event type, such as a Fall

4. 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 - event • Skin tear with fungal infection that developed under brace • Skin excoriation on buttocks Fall … associated with patient care • Fall from bed with minor injuries (elbow, knees, and small skin tear

5. AHRQ Slide Template 2019-Widescreen (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
   January 01, 2020 - AHRQ Slide Template 2019-Widescreen Working With Patient Safety Organizations (PSOs) – The Value for Hospitals During COVID-19 and Beyond We will get started in just a few minutes. Housekeeping All lines are currently muted. We will have a Q&A period at the end of the presentation. Chat Function: Use chat to a…

6. Network of Patient Safety Databases (NPSD) Chartbooks | PSO
   pso.ahrq.gov/common-formats/npsd-chartbooks
   April 01, 2025 - SHARE: More topics in this section Data Common Formats Network of Patient Safety Databases (NPSD) Dashboards Network of Patient Safety Databases (NPSD) Chartbooks Network of Patient Safety Databases (NPSD) Data Spotlights About …

7. Network of Patient Safety Databases (NPSD) Dashboards | PSO
   pso.ahrq.gov/common-formats/npsd-dashboards
   November 01, 2024 - SHARE: More topics in this section Data Common Formats Network of Patient Safety Databases (NPSD) Dashboards Network of Patient Safety Databases (NPSD) Chartbooks Network of Patient Safety Databases (NPSD) Data Spotlights About …

8. Organizations and Relationships | PSO
   pso.ahrq.gov/about/organizations
   November 01, 2023 - SHARE: More topics in this section About About Organizations and Relationships Organizations and Relationships Congress authorized the Secretary of the U.S. Department of Health and Human Services (HHS) to implement an…

9. 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 - Falls Dashboard The Falls Dashboard details the extent of harm due to falls, the presence of fall … assistance, the presence of fall assistance by patient harm, the type of fall injury, and fall location … The contract was expanded in fall 2009 to offer participation to all 50 States, the District of Columbia

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 - How PSOs Help Health Care Organizations Improve Patient Safety Culture How PSOs Help Health Care Organizations Improve Patient Safety Culture Developing a culture of safety is an essential task for health care organizations as they strive to eliminate the factors that contribute to medical errors, patient harm, …