CPS Releases Annual PSO Report

March 24, 2015    |   By: Calevir

The Center for Patient Safety has released the 2014 PSO Report, containing findings reported by healthcare providers.

The data contained in the report is from the Center for Patient Safety’s PSO database. Licensed healthcare providers may participate in a PSO in order to share information, learn from the sharing, gain federal protection to support open reporting and ultimately reduce mistakes and patient harm. PSO participation is voluntary and organizations may choose to submit most or all adverse events or they may choose to submit only the more severe adverse events to share lessons learned. The event types and their severities, along with additional information, contained in the report are deidentified as required by the PSQIA.

The goal of the report is to present an overview of the findings within all of the events reported to the Center’s PSO, to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.

General CPS findings include:

  • 27,000+ events from 110 healthcare organizations.
  • 6% of reported events are near-misses and unsafe conditions, in which a mistake or error was about to occur, or could have occurred, but was caught before it reached the patient. These cases are excellent stories to learn more about preventing patient harm. Fortunately many more near misses occur than events that reach the patient.
  • 94% of reported events reached the patient, an incident. An incident is an event that occurred in a healthcare setting and directly impacted a patient.
  • 27% of reported incidents resulted in patient harm.
  • 1.2% of reported events resulted in severe harm or death.

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