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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 - infection and subsequent partial dehiscence due to inadequate wound care • Wound infection of below … 2 nasal pressure ulcer associated with face mask • Deep tissue injuries related to ace wraps • New stage … 2 sacral pressure ulcer • Progression of stage 2 to stage 3 sacral pressure ulcer • Sacral pressure … injury of sacral area • Suspected deep tissue injury of the sacrum • Worsening pressure ulcer of sacrum … Bleeding not directly associated with anticoagulants • Gross hematuria due to trauma from urinary catheter

2. Adverse and Temporary Harm Events in Rehabilitation Hospitals Designated in OIG Report as Clearly Preventable or Likely Preventable by Clinical Category (pdf file)
   pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
   July 01, 2016 - and agitation secondary to benzodiazepine led to patient pulling urinary catheter with resultant injury … 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

3. AHRQ Slide Template 2019-Widescreen (pdf file)
   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