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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - Adverse Events Related to Patient Care
Exacerbations of preexisting conditions and other deteriorating medical … brace
• Skin excoriation on buttocks
Fall associated with patient care
• Fall from bed with minor injuries … (elbow, knees, and small skin tear)
Device trauma or malfunction
• Clotted arteriovenous shunt (dialysis … access device)
• Trauma due to multiple failed Foley catheter insertions
Edema or volume overload
• … erythema on right thigh
Surgical Site Infection (SSI)
• Superficial infection that developed on existing wound
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - tract infection (CAUTI)
Soft tissue or other nonsurgical infections
• Infected, necrotic chest wall wound … infections
Surgical-site infections
• Cellulitis at PEG site
• Infection at site of ankle surgery
• Late wound … infection and subsequent partial dehiscence due to inadequate wound care
• Wound infection of below … Patient Care
Pressure ulcers
• Stage 2 nasal pressure ulcer associated with face mask
• Deep tissue injuries … not directly associated with anticoagulants
• Gross hematuria due to trauma from urinary catheter placement
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pso.ahrq.gov/about/webinar-nov5
November 01, 2020 - the Surgeon General, and gained expertise in legal matters related to research misconduct, graduate medical … She is a neurologic clinical specialist in physical therapy with focus areas in stroke and brain injury … began her career as a registered nurse in the Pediatric Intensive Care Unit at Vanderbilt University Medical … Van Buren served as the Vice President of Medical Services with healthcare consulting firms, Providers
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pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
January 01, 2020 - Late, Planned,
Unplanned
• Restraint Utilization
• Falls/Unassisted Falls
o By Diagnosis Group
• Injuries … Resulting from
Falls/Unassisted Falls
o By Diagnosis Group
• Pressure Injuries
• Venous Thromboembolism … Sharing
2019
• Our Recent TJC Survey Experience
• Eliminating CAUTI among patients with spinal cord injuries
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pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
January 04, 2025 - while under a provider’s care, the tort
system offers an avenue to compensate
the patient for his injury … injury, the general threat
of litigation provides a disincentive to
providers from voluntarily sharing … For example, CMS’ Hospital CoP for medical record
services includes that a hospital’s medical record … Information related to the func-
tioning of medical equipment. … As part of the patient’s original
medical record 22.
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pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf
December 21, 2021 - practices that target prevention of specific
harms, such as healthcare-associated infections and pressure injuries … the presence of fall assistance,
the presence of fall assistance by patient harm, the type of fall injury … private-public partnerships
to: (1) identify the causes of preventable health care
errors and patient injury … of Evidence (Not reviewed) (Not reviewed)
Interventions To Prevent Contrast-Induced Acute Kidney Injury … Summary of Evidence Update (Not reviewed)
Preventing Patient Death or Serious Injury Associated With
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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 and injury … Medical doctors are just one example of licensed or certified medical professionals who may meet this … professionals with contracted medical professionals? … Is a PSO required to have licensed or certified medical professionals as part of its workforce? … be a PSO specializing in pediatric safety events that has a currently licensed medical professional