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Total Results: 21 records

Showing results for "harm".

1. Related Office of Inspector General (OIG) Reports | PSO
   pso.ahrq.gov/resources/oig-reports
   August 01, 2025 - disseminating information related to these reports to increase understanding of adverse events and harm … Acute-care Hospitals: Hospitals Did Not Capture Half of Patient Harm Events, Limiting Information Needed … Care Safer (July 24, 2025) Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm … Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries (November 2018) Adverse and Temporary Harm … Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries (July 2016) Adverse and Temporary Harm

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 … 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

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 - development of this effort to explore where the use of AI in healthcare may unintentionally result in harm … and to develop and disseminate resources to prevent such harm from occurring in the future. … or potential harm as a result of unintended algorithm behavior, either from an incorrect action from … safety; • Promoting the identification of events where AI deployed in healthcare settings may cause harm … data analyses and supporting the creation and dissemination of resources to prevent or mitigate such harm

4. 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 … 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

5. Resources for Artificial Intelligence (AI) in Healthcare Safety | PSO
   pso.ahrq.gov/resources/ai-healthcare-safety
   February 01, 2025 - Patient Safety Organization (PSO) Program to identify where AI deployed in healthcare settings may cause harm … and to learn from such occurrences to prevent such harm from occurring in the future.

6. Resources | PSO
   pso.ahrq.gov/resources
   October 01, 2024 - Intelligence (AI) in Healthcare Safety program, which furthers the identification and reduction of potential harm

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 - type by extent of harm, and extent of harm. … It details the extent of harm due to devices; type of device; type of device by patient harm; device … process where event originated by patient harm. … They are common, they can cause significant harm, and they are often preventable. … Reducing preventable harm: observations on minimizing bloodstream infections.

8. About Network of Patient Safety Databases (NPSD) | PSO
   pso.ahrq.gov/common-formats/about-npsd
   November 01, 2024 - valuable resource for research and learning about how to improve patient safety and prevent patient harm

9. What are "patient safety activities"? | PSO
   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

10. PSO General Information
    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

11. PSO Quiz--Question Sheet (pdf file)
    pso.ahrq.gov/sites/default/files/quiz/pso-quiz-questions.pdf
    January 01, 2020 - An operating room nurse observes a mistake by a physician during an operation that leads to patient harm

12. Choosing a Patient Safety Organization (pdf file)
    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

13. 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 - organizations as they strive to eliminate the factors that contribute to medical errors, patient harm … errors are treated not as personal failures, but as opportunities to improve the system and prevent harm … Improved Safety Culture and Teamwork Climate Are Associated With Decreases in Patient Harm and Hospital

14. How To Choose a PSO | PSO
    pso.ahrq.gov/work-with/choose
    November 01, 2020 - collection and reporting of patient safety events and to improve healthcare providers’ efforts to eliminate harm

15. About Common Formats | PSO
    pso.ahrq.gov/common-formats/about
    November 01, 2024 - used to report: Incidents: patient safety events that reached the patient, whether or not there was harm

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 - and reporting of patient safety events and to improve health care providers’ efforts to eliminate harm

17. Benefits of AHRQ Patient Safety Organizations (PSOs): Success Stories From Hospital PSO Members (pdf file)
    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

18. Data | PSO
    pso.ahrq.gov/common-formats
    June 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 …

19. PSO Quiz--Answer Sheet (pdf file)
    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

20. Frequently Asked Questions | PSO
    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