-
pso.ahrq.gov/sites/default/files/wysiwyg/ChoosingPSO_2016.pdf
January 01, 2016 - But achieving this
goal is no small feat.
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pso.ahrq.gov/sites/default/files/wysiwyg/adverse-events-rehab-hospitals.pdf
July 01, 2016 - buttocks
Fall associated with patient care
• Fall from bed with minor injuries (elbow, knees, and small
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pso.ahrq.gov/sites/default/files/wysiwyg/oig-list-long-term-care-hospitals-2019.pdf
January 01, 2019 - dehiscence due to inadequate wound care
• Wound infection of below knee amputation suture line with small
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pso.ahrq.gov/sites/default/files/wysiwyg/strategies-to-improve-patient-safety_draft-report.pdf
December 21, 2021 - Professor James Reason’s “Swiss cheese model” of accident causation illustrates how small flaws or
weaknesses … multiple layers of defenses, barriers, and safeguards (akin to the slices of
Swiss cheese), but when small … This awareness keeps team members at all levels able to identify and
address small issues that could … PMID: 727541.
22 Small SD, Barach P. Patient safety and health policy: a history and review. … For example, an intervention that effectively
reduced adverse events in a small hospital might be scaled
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pso.ahrq.gov/sites/default/files/wysiwyg/ai-healthcare-safety-program.pdf
July 01, 2025 - Healthcare Safety Program specifically, the conference closed with a
discussion session that included small