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pso.ahrq.gov/pso/alliance-patient-medication-safety
December 10, 2008 - section
Return to Search
Alliance for Patient Medication
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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - as Clearly Preventable or Likely Preventable,
by Clinical Category
Adverse Events Related to Medication … used to treat hypertension
Dehydration and related electrolyte disorders associated with medication … Nausea and vomiting secondary to medication
• Nausea and vomiting due to opioid pain medication
Hypoglycemic … events due to medication
• Multiple, severe symptomatic hypoglycemic episodes characterized by a period … to medication
• Significant diarrhea secondary to stool softener
Other medication temporary harm events
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - with other event types
• Cascade with candidemia with widespread infection treated with ineffective medication … (risperidone) and opioid (oxycodone)
• Failure to identify and treat delirium due to multiple medication … (fentanyl)
• Hallucinations and agitation while on opioid analgesic medication (fentanyl and meperidine … )
• Lethargy while on antipsychotic (haloperidol) medication
• Lethargy while on multiple psychotropic … • Somnolence while on anti-anxiety medication (alprazolam)
• Somnolence while on opioids (intravenous
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pso.ahrq.gov/sites/default/files/wysiwyg/OnDemand%20Webinar%20Slides%20-%20June%2010%202015.pdf
January 01, 2010 - ► Reporting a medication with nearly identical labels led to a
national change in the label. … • PSO Alert – High Alert Medications
► 1 in 5 medication errors reported to PSO in 2014 involved … Standards
• Like many children’s hospitals we have major issues
with medication safety
► Dosing … Standards
• Need a statewide compounded oral medication
standard
► But how to do this? … Standards
Medication Standards
Lessons Learned and Evolving Needs
Value of the PSO Program
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pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
July 01, 2025 - Additional NPSD data tools include
annual Chartbooks, with a focus on fall events in
202311 and medication … Malfunction of
medication dispensing
system
Nurse removing medication from
[medication dispensing … system froze
during neurosurgical procedure
causing delay of 40[-] 60 minutes
Improper use of
medication … dispensing
system
Pharmacist discovered no TPA
stored in [medication dispensing
system]. … The medication should
never be empty.
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pso.ahrq.gov/common-formats/npsd-chartbooks
April 01, 2025 - Topic Specific Chartbooks: 2024 NPSD Medication Chartbook (PDF, 4 MB) 2023 NPSD Falls Chartbook (PDF
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pso.ahrq.gov/about/organizations
November 01, 2023 - The NPSD receives nonidentifiable data from the PSOPPC on patient safety concerns such as falls and medication
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pso.ahrq.gov/work-with/choose
November 01, 2020 - Some PSOs specialize by topic area, such as anesthesia or medication adverse events, so you may want
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pso.ahrq.gov/sites/default/files/wysiwyg/working-with-pso-webinar-value-hospitals.pdf
January 01, 2020 - attestations, flow of patient safety work product
• Organized and chartered quarterly Patient Safety and Medication … Survey Experience
• Eliminating CAUTI among patients with spinal cord injuries
• PME: Personalized Medication
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pso.ahrq.gov/sites/default/files/Choosing%20a%20PSO.pdf
August 01, 2012 - Some PSOs specialize by
topic area, such as anesthesia or medication adverse
PATIENT
SAFETY
Choosing
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pso.ahrq.gov/pso/listed
Tennessee Components of Parent Organizations: AHS Legacy Operations, LLC
Alliance for Patient Medication
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pso.ahrq.gov/sites/default/files/wysiwyg/pso-brochure.pdf
March 01, 2020 - Some PSOs specialize in a specific area, such as
anesthesia or medication adverse events, or focus on
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pso.ahrq.gov/pso/emergency-medical-error-reduction-group-0
March 08, 2022 - SHARE:
More topics in this section
Return to Delisted PSOs Search
Emergency Medical Error Reduction Group
PSO Number: P0235 Components of Parent Org(s):
Center for Leadership, Inn…
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pso.ahrq.gov/pso/academic-medical-center-amc-pso
December 22, 2010 - SHARE:
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Return to Search
Academic Medical Center (AMC) PSO
PSO Number: P0103 Components of Parent Org(s):
Risk Management Foundation of the Harvard Medi…
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pso.ahrq.gov/pso/emergency-medical-error-reduction-group
November 28, 2012 - SHARE:
More topics in this section
Return to Delisted PSOs Search
Emergency Medical Error Reduction Group
PSO Number: P0133 Components of Parent Org(s):
Center for Leadership, Inn…
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pso.ahrq.gov/pso/community-medical-foundation-patient-safety
January 07, 2009 - SHARE:
More topics in this section
Return to Delisted PSOs Search
Community Medical Foundation for Patient Safety
PSO Number: P0029 Components of Parent Org(s): N/A
Effe…
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pso.ahrq.gov/pso/american-medical-foundation-patient-safety-organization
March 13, 2013 - SHARE:
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Return to Search
American Medical Foundation Patient Safety Organization
PSO Number: P0141 Components of Parent Org(s):
American Medical Foundat…
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pso.ahrq.gov/pso/delisted/printable-list
December 17, 2008 - Institute for Safe Medication Practices (ISMP) PSO Number: P0009 Components of Parent Org(s): … 00 am
Reason for Delisting: Voluntary Relinquishment Additional Comment: The Institute for Safe Medication … PSO changed its name to reflect this agreement and has now become the ECRI and the Institute for Safe Medication
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pso.ahrq.gov/pso/listed/geographic/printable-list
None Subject to FDA-Regulated Reporting Entity Guidance: No
ECRI and the Institute for Safe Medication … Findings: None Subject to FDA-Regulated Reporting Entity Guidance: No
Alliance for Patient Medication
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pso.ahrq.gov/common-formats/npsd-dashboards
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 …