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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 - hospital • Soft tissue infection at PICC entrance site extending into axilla Urinary tract infections … infection • Clostridium difficile infection • Clostridium difficile infection • Clostridium difficile … infection • Clostridium difficile infection • Clostridium difficile infection • Clostridium difficile … infection LTCH-acquired respiratory infections Surgical-site infections • Cellulitis at PEG site • … associated infections • Cellulitis/abscess at PICC site • Central line infection followed by sepsis

2. AHRQ Slide Template 2019-Widescreen (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
   January 01, 2020 - Comparison Groups: Acuity, Size, IRF/IRU Quarterly conference calls/Safe Tables • General webinar and Infection … Falls o By Diagnosis Group • Pressure Injuries • Venous Thromboembolism • Healthcare-Associated MRSA Infections … • Healthcare-Associated C.difficile Infections • Healthcare-Associated CAUTI Infections • Oncology … Influenza Outbreak Management in Rehabilitation Settings • School of Nursing Outreach Program • Writing an Infection … Falls MRSA Bacteremia LabID Events C. difficile LabID Events Catheter-Associated Urinary Tract Infections

3. 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 - Hemorrhagic cystitis in patient associated with Foley catheter and anticoagulant Adverse Events Related to Infections … infection (Escherichia coli) • Catheter-associated urinary tract infection (Enterobacter) Clostridium … difficile infection • Clostridium difficile infection secondary to antibiotics • Cascade event in which … extremity pitting edema Other patient care temporary harm events Temporary Harm Events Related to Infections … area • Blisters and erythema on right thigh Surgical Site Infection (SSI) • Superficial infection that

4. 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 - Infection Control: Central Line-Associated Bloodstream Infections.................................... … Infection Control: Infections Due to Other Multi-Drug-Resistant Organisms............................ … Infection Control: Central Line-Associated Bloodstream Infections Patient Safety Practices MHS I ( … Infection Control: Central Line-Associated Bloodstream Infections Table 18. … Infection Control: Infections Due to Other Multi-Drug-Resistant Organisms Table 20.

5. 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 - patients of abnormal test results ■ Factors related to falls ■ Prevention of health care-associated infections … 2014) On the CUSP: Stop BSI: Evaluating the relationship between central line-associated bloodstream infection … rate and patient safety climate profile. (2014) American Journal of Infection Control. 2014 42:S203

6. Other Patient Safety and Quality Improvement Resources | PSO
   pso.ahrq.gov/resources/other
   August 01, 2022 - SHARE: More topics in this section Resources Resources Resources About the Patient Safety and Quality Improvement Act of 2005 Resources for Improving Patient Safety and Healthcare Quality Reducing Avoidable Hospital Readmissions …

7. 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 - safety directly, for example, to attempt to prevent major adverse events such as healthcare- associated infections