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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 … aspiration pneumonia led to hypotension resulting in transfer to an
acute-care hospital
Temporary Harm … to treat gastro esophageal reflux disease
• Urinary retention secondary to antihistamine
Temporary Harm … events
Temporary Harm Events Related to Infections
Soft tissue or other nonsurgical infection
• Yeast
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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 … Clearly Preventable or Likely Preventable, by Clinical Category
Page 1 of 9
Adverse and Temporary Harm … delayed diagnosis of urinary retention leading to nausea/vomiting and
aspiration pneumonia
Temporary Harm … medication
• Seizure related to withdrawal of anticonvulsant medication (levetiracetam)
Temporary Harm … to ventricular tachycardia
• Hyperkalemia (potassium of 6.2)
Other patient-care-related temporary harm
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pso.ahrq.gov/faq/what-are-patient-safety-activities
participants in a patient safety evaluation system
The term "safety" refers to reducing risk from harm
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pso.ahrq.gov/taxonomy/term/2/feed
April 23, 2019 - participants in a patient safety evaluation system
The term "safety" refers to reducing risk from harm
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pso.ahrq.gov/sites/default/files/wysiwyg/pso-brochure.pdf
March 01, 2020 - including providers, for
research and learning about how to improve
patient safety and prevent patient harm … valuable resource for research and
learning about how to improve patient safety and
prevent patient harm
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pso.ahrq.gov/sites/default/files/wysiwyg/OnDemand%20Webinar%20Slides%20-%20June%2010%202015.pdf
January 01, 2010 - contracting with the PSO, our focus was on
reporting actual events that reached the patient
and/or caused harm … families did not know about the error
► Quickly settle claims
► Share openly experiences about mistakes/harm
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pso.ahrq.gov/sites/default/files/quiz/pso-quiz-answer-sheet.pdf
January 01, 2020 - An operating room nurse observes a mistake by a physician during an operation that leads to
patient harm
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pso.ahrq.gov/faq
April 01, 2023 - participants in a patient safety evaluation system
The term "safety" refers to reducing risk from harm … be used for:
Incidents: patient safety events that reached the patient, whether or not there was harm