Patient Safety Organizations (PSOs) support the collection, analysis, sharing and learning about what medical errors occur, why they occur and how to prevent them. Additionally, the law provides confidentiality protections and privilege protections (inability to introduce the protected information in a legal proceeding), when certain requirements are met.
In July 2005, Congress developed the federal Patient Safety and Quality Improvement Act of 2005 in response to the Institute of Medicine report, To Err Is Human. The final Patient Safety Rule was adopted November 21, 2008 and became effective on January 19, 2009. The Agency for Healthcare Research and Quality, one of the eleven divisions under the Department of Health and Human Services, oversees the Patient Safety Rule.
The Patient Safety Act and the Patient Safety Rule provide a structure for PSOs while the legislation affords protection for physicians and healthcare providers that voluntarily and confidential reporting of adverse event information to designated PSOs. The program intentionally differentiates PSO work from most regulatory and mandatory reporting programs.
In 2008, the Center for Patient Safety was the 5th federally-designated PSO in the country. The goal of the Center for Patient Safety PSO is to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.
The Patient Safety Act and the Patient Safety Rule reinforce a safety culture that encourages and allows healthcare providers to safely report and share information about vulnerabilities within the healthcare system. The Act extends confidentiality and privilege protections to:
When a provider works with a PSO, many of the long-recognized impediments to successful improvement projects can be overcome:
Focusing on Both Deaths and Harm from Medical Errors In his latest post to the “Line of Sight” blog, IHI President and CEO, Derek Feeley, reflects on the controversy and criticism surrounding a recent
A study completed at The Ohio State University, and published in the American Journal of Medical Quality, shows a patient safety cultural transformation after implementation of Crew Resource Management.
Take a few minutes and read this article from JEMS magazine. Developing a just culture or a model of shared accountability can offer improvements for greater patient and provider safety. Likewise, cons
The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.