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pso.ahrq.gov/contact
February 01, 2025 - about the Patient Safety Act and Rule, PSO listing process, listed PSOs, and other PSO operational issues
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pso.ahrq.gov/sites/default/files/wysiwyg/OnDemand%20Webinar%20Slides%20-%20June%2010%202015.pdf
January 01, 2010 - every quarter
• We expected to be “leaders and best” but this is not
always true
► Problems and issues … We are actually ahead of the curve
34
The PSO’s fulfillment of our needs
• We have lots of issues … • PSO helps with all of these issues
► Reading publications is very helpful but does not
answer all … any topic
35
Pediatric Medication Standards
• Like many children’s hospitals we have major issues … • Report your events so we can “all teach, all learn”
• How to prioritize issues?
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pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
January 01, 2020 - • COVID-19
► Increased stress on healthcare systems
► Potential new patient safety issues
• PSOs … and Medication Safety Councils of
subject matter experts, CHS PSO and member staff
– Review current issues … in our industry, trends, issues, common causes
– Prioritize and focus patient safety and quality efforts … of inpatient rehabilitation in the care
continuum
• Provides a “safety zone” to discuss sensitive issues
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pso.ahrq.gov/resources/ai-healthcare-safety
February 01, 2025 - Meeting (PDF, 146 KB) Measuring and Assessing AI and Safety: Educational Brief 58: AI/algorithm-related Issues
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pso.ahrq.gov/
PSO Brochure This PDF brochure describes provider benefits of working with a PSO and issues to consider
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pso.ahrq.gov/resources/guides
August 01, 2023 - The model this video reviews is intended to raise many—but certainly not all—of the issues that a provider
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pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
July 01, 2025 - Narratives in Device/HIT Events
25
23 Figure from Educational Brief 58: AI/algorithm-related Issues … items, such as words or characters, in text.
25 Figure from Educational Brief 58: AI/algorithm-related Issues … examination of the narratives identified from the NLP approach revealed examples of potential
AI/HIT-related issues … responses and free text
narratives, can accommodate the reporting of at least some healthcare safety issues
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pso.ahrq.gov/sites/default/files/wysiwyg/npsdpatient-safety-culture-brief.pdf
September 01, 2016 - safety culture
assessment, health care organizations can assess staff
attitudes about patient safety issues … Tables promote a culture of trust
that encourages open dialogue by PSO members about
patient safety issues
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pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf
December 21, 2021 - It also addresses public notice requirements and issues related to disposition of protected
data when … This awareness keeps team members at all levels able to identify and
address small issues that could … The grants
emphasized engagement of patients in funded research and addressed a broad array of issues … Areas of research include technical
skills, team performance, system performance, methodological issues … Having someone at the State or national level to contact when they
had issues, or to share successes
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - Syndrome secondary to allopurinol
Page 4 of 9
Adverse Events Related to Patient Care
Respiratory issues … Acute kidney injury or insufficiency
• Hyperkalemia secondary to acute kidney injury
Respiratory issues
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pso.ahrq.gov/sites/default/files/wysiwyg/PSO_Disclosure.pdf
September 30, 2024 - may wish to contact the AHRQ PSO Office to discuss the nature of your
disclosure or to clarify any issues
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pso.ahrq.gov/sites/default/files/wysiwyg/PSO-listing-guide-2022.pdf
January 01, 2022 - The model this video reviews is intended to raise many - but certainly not all - of the issues
that … is the scope of the PSO’s existing and
planned dissemination activities (i.e., is it
restricted to issues … between
the expertise and skills of its medical
professional(s) and the clinical patient safety
issues … security policies and procedures (Rows #5 and #6 above)
adequately and appropriately address these issues … security policies and procedures (Rows #5 and #6 above)
adequately and appropriately address these issues
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pso.ahrq.gov/about
October 01, 2020 - SHARE:
More topics in this section
About
About
Organizations and Relationships
About the PSO Program
A Brief History of the Program
The Congress developed and enacted the Patient Safety and Quality Improvement A…
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pso.ahrq.gov/sites/default/files/wysiwyg/fda-guidance-pso.pdf
December 01, 2010 - Given the issues identified in this Guidance,
AHRQ will also be engaging in additional inquiry of applicants
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pso.ahrq.gov/resources/acronyms
August 01, 2021 - Patient Safety Act Guidance – HHS issues guidance to describe or explain certain aspects of the Patient
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pso.ahrq.gov/sites/default/files/wysiwyg/guidance-pswp-provider-obligations.pdf
May 24, 2016 - with non-PSWP to satisfy this requirement, ‘‘regardless
of whether such additional analysis involves issues
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pso.ahrq.gov/sites/default/files/wysiwyg/pso-program-acronyms.pdf
October 01, 2022 - Patient Safety Act Guidance – HHS issues guidance to describe or explain certain aspects of the Patient
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pso.ahrq.gov/resources/rule
August 01, 2022 - SHARE:
More topics in this section
Resources
Resources
Resources About the Patient Safety and Quality Improvement Act of 2005
Patient Safety Act
Patient Safety Rule
HHS Guidance
Guides
Other Educational Materials
…
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pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
January 04, 2025 - with non-PSWP to satisfy this
requirement, ‘‘regardless of whether
such additional analysis involves issues
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pso.ahrq.gov/sites/default/files/wysiwyg/PSO_BonaFideContracts.pdf
September 30, 2024 - Patient Safety Organization: Two Bona Fide Contracts Requirement
…