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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 - care • Cascade with opioids (respiratory depressant) complicated by morbid obesity and sleep apnea leading … to aspiration pneumonia • Cascade with respiratory infection while on ventilator leading to acute kidney … an acute-care hospital and contributing to death • Cascade with stage-4 infected pressure ulcer leading … to death • Cascade beginning with delirium leading to the dislodgement of the tracheal tube by the … to electrolyte imbalance leading to ventricular tachycardia • Hyperkalemia (potassium of 6.2) Other

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 - 53 Leading Quality and Safety “Success teaches us nothing; only failure teaches…Develop the capacity … 2019 AHA Quest For Quality Prize Value of Sharing Through a PSO Value of Sharing Through a PSO Leading

3. 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, …

4. Webinar on Working With Patient Safety Organizations (PSOs): The Value for Hospitals During COVID-19 and Beyond | PSO
   pso.ahrq.gov/about/webinar-nov5
   November 01, 2020 - SHARE: More topics in this section About About Organizations and Relationships Webinar on Working With Patient Safety Organizations (PSOs): The Value for Hospitals During COVID-19 and Beyond Summary This webinar will…

5. Resources for Improving Patient Safety and Healthcare Quality | PSO
   pso.ahrq.gov/resources/improving-patient-safety
   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 …

6. About Network of Patient Safety Databases (NPSD) | PSO
   pso.ahrq.gov/common-formats/about-npsd
   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 …

7. Contact the PSO Program | PSO
   pso.ahrq.gov/contact
   February 01, 2025 - SHARE: More topics in this section Contact PSO Subscribe to Email Updates Contact the PSO Program AHRQ PSO Program Contact the AHRQ PSO Program for more information about the Patient Safety Act and Rule, PSO listing process,…

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. PSO Quiz--Question Sheet (pdf file)
   pso.ahrq.gov/sites/default/files/quiz/pso-quiz-questions.pdf
   January 01, 2020 - PSO Quiz--Question Sheet QUIZ —QUESTION SHEET Page 1 of 3 Question 1 of 12 A PSO that changes its Authorized Official is expected to notify AHRQ of the change no later than when the PSO submits its next certifications for continued listing. Choose one: True False Question 2 of 12 A PSO should notif…

10. Reducing Avoidable Hospital Readmissions: The Role of the Patient Safety Organization (PSO) | PSO
    pso.ahrq.gov/resources/readmission
    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 …

11. PSO Quiz--Answer Sheet (pdf file)
    pso.ahrq.gov/sites/default/files/quiz/pso-quiz-answer-sheet.pdf
    January 01, 2020 - PSO Quiz--Answer Sheet QUIZ —AN…

12. 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 - Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the National Academy of Medicine iiiiR& Agency for Healthcare Research and Quality Strategies to Improve Patient Safety: Draft Report to Congress for Public Comment and Review by the Nation…

13. 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 - preventable patient harm by engaging, educating and equipping patient-care teams to put evidence-based leading

14. Frequently Asked Questions | PSO
    pso.ahrq.gov/faq
    April 01, 2023 - SHARE: Frequently Asked Questions Frequently asked questions and definition of terms used in the Patient Safety Act or Patient Safety Rule are summarized here solely for convenience; always rely on the actual text of the Patient Safety Act or Patient Safety …

15. Fedregnotice-05242016 (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
    January 04, 2025 - 32655 Federal Register / Vol. 81, No. 100 / Tuesday, May 24, 2016 / Rules and Regulations 1 Institute of Medicine, ‘‘To Err Is Human: Building a Safer Health System’’, 1999, page 86. 2 42 CFR 482.21(a)(2). 3 As of November 2014, 26 states and the District of Columbia had adverse event reporting systems, and Te…

16. Patient Safety Organization (PSO) Listing Guide (pdf file)
    pso.ahrq.gov/sites/default/files/wysiwyg/PSO-listing-guide-2022.pdf
    January 01, 2022 - Patient Safety Organization (PSO) Listing Guide PATIENT SAFETY ORGANIZATION (PSO) LISTING GUIDE What is the PSO Listing Guide? The PSO Listing Guide is an informal educational resource to help readers locate and learn about the requirements for PSO listing under the Patient Safety and Quality Improveme…