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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - )
Delirium and other changes in mental status
• Cascade with oversedation while on multiple opioid medications … pain medication (morphine immediate release)
• Cascade with confusion while on multiple psychotropic medications … (opioids and antidepressants)
• Delirium due to multiple sedating medications, including opioid pain … medication
(intravenous hydromorphone), multiple psychotropic medications, and gabapentin
• Delirium … Lethargy while on antipsychotic (haloperidol) medication
• Lethargy while on multiple psychotropic medications
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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - Clinical Category
Adverse Events Related to Medication
Delirium or change in mental status due to medications … Confusion and lethargy secondary to opioid pain medication
• Lethargy and confusion secondary to multiple medications … benzodiazepine
• Lethargy secondary to opioid pain medication
• Sedation and lethargy secondary to antianxiety medications … medication
• Significant constipation secondary to opioid pain medication
Allergic reactions to medications … site with associated decreased hemoglobin secondary to
anticoagulants
• Nausea and vomiting due to medications
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pso.ahrq.gov/sites/default/files/wysiwyg/OnDemand%20Webinar%20Slides%20-%20June%2010%202015.pdf
January 01, 2010 - • PSO Alert – High Alert Medications
► 1 in 5 medication errors reported to PSO in 2014 involved … high alert medications … yields 3/day that are wrong
o Not good enough for a high reliability organization
► Compounded oral medications
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pso.ahrq.gov/pso/alliance-patient-medication-safety
December 10, 2008 - SHARE:
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Alliance for Patient Medication Safety
PSO Number: P0020 Components of Parent Org(s):
National Alliance of State Pharmacy Associations (…
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pso.ahrq.gov/pso/emergency-medical-error-reduction-group-0
March 08, 2022 - SHARE:
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Emergency Medical Error Reduction Group
PSO Number: P0235 Components of Parent Org(s):
Center for Leadership, Innovation a…
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pso.ahrq.gov/pso/fresenius-medical-care-pso-llc
January 06, 2017 - SHARE:
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Fresenius Medical Care PSO, LLC
PSO Number: P0081 Components of Parent Org(s):
Fresenius Medical Care Holdings, Inc.
…
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pso.ahrq.gov/pso/community-medical-foundation-patient-safety
January 07, 2009 - SHARE:
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Community Medical Foundation for Patient Safety
PSO Number: P0029 Components of Parent Org(s):
Effective Date an…
-
pso.ahrq.gov/pso/emergency-medical-error-reduction-group
November 28, 2012 - SHARE:
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Emergency Medical Error Reduction Group
PSO Number: P0133 Components of Parent Org(s):
Center for Leadership, Innovation a…
-
pso.ahrq.gov/pso/academic-medical-center-amc-pso
December 22, 2010 - SHARE:
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Academic Medical Center (AMC) PSO
PSO Number: P0103 Components of Parent Org(s):
Risk Management Foundation of the Harvard Medical Insti…
-
pso.ahrq.gov/pso/american-medical-foundation-patient-safety-organization
March 13, 2013 - SHARE:
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American Medical Foundation Patient Safety Organization
PSO Number: P0141 Components of Parent Org(s):
American Medical Foundation for P…
-
pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf
December 21, 2021 - particular clinical interventions, such as medications … healthcare-associated infections;
diagnostic safety and quality; the safe use of
medical devices and medications … for patients with multiple chronic conditions; the
role of labeling, packaging, and distribution of medications
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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 …
-
pso.ahrq.gov/sites/default/files/wysiwyg/fedregnotice-05242016.pdf
January 04, 2024 - 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…
-
pso.ahrq.gov/pso/delisted
January 25, 1991 - SHARE:
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Search
Delisted PSOs
Below are PSOs that have been delisted. A PSO may be “delisted” for three reasons:
Voluntary Relinquishment — the PSO …
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pso.ahrq.gov/about/webinar-nov5
November 01, 2020 - SHARE:
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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…
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pso.ahrq.gov/pso/listed
SHARE:
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Filter Results:
States and Territories Served Serves All States and Territories
(48)
Alabama
(64)
Alaska
(58)
American Sa…
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pso.ahrq.gov/resources/act
August 01, 2022 - SHARE:
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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
…
-
pso.ahrq.gov/sites/default/files/quiz/pso-quiz-answer-sheet.pdf
January 01, 2020 - PSO Quiz--Answer Sheet
QUIZ —AN…
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pso.ahrq.gov/pso/delisted/printable-list
December 17, 2008 - SHARE:
Delisted PSOs
Below are PSOs that have been delisted. A PSO may be “delisted” for three reasons:
Voluntary Relinquishment — the PSO chooses to voluntarily relinquish its status as a PSO.
Failure to Seek Continued Listing — the 3-year listing period expires …
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pso.ahrq.gov/sites/default/files/wysiwyg/guidance-pswp-provider-obligations.pdf
May 24, 2016 - Slide 1
Patient Safety and Quality Improvement Act of 2005—HHS
Guidance Regarding Patient Safety Work Product and
Providers’ External Obligations
Effective Date: May 24, 2016
1
Overview
of the
Guidance Document
2
Why Was The Guidance Issued?
• Clarify what information that a provider
cre…