PSO 101: Introduction to PSOs

November 17 @ 12pm CST   – Free webinar

Questions and Answers signpostConfused about Patient Safety Organizations (PSOs)?   You’re not alone!

Join the experts at the Center for Patient Safety as they describe the basics of the Patient Safety and Quality Improvement Act (PSQIA) and provide an introduction to the terminology and concepts of PSO participation.  Applications to EMS, LTC, medical offices, and hospitals will be presented.   Q&A available during webinar.   Register

About Patient Safety Organizations (PSOs): Did You Know?

Now that Patient Safety Organizations (PSOs) have been in existence for more than five years, the federal Patient Safety and Quality Improvement Act (PSQIA) is better understood, and knowledge about the Act has increased. Still, there are a number of questions we commonly receive at the Center for Patient Safety.   Here are the top 10 questions, answered by the Center’s Patient Safety Specialist, Eunice Halverson at [email protected]:

Why should a health care provider join a PSO?
PSOs are independent, external experts who can collect, analyze and aggregate patient safety work product to develop insights into the underlying causes of patient safety events. Communications with PSOs are protected to allay fears of increased liability or fear of sanctions. With this federal protection, healthcare providers can share information with other participants, via the PSO, and learn from each other to ultimately improve patient care. More information is available from the AHRQ on working with a PSO.

(more…)

Center releases Fall 2014 EMS PSO Newsletter

Fall EMS 2014The latest newsletter from the Center for Patient Safety has been released. The Fall 2014 EMS PSONews contains information on the recently released PSO Safety Alert and EMS Safety Watch, articles on the legal environment to help maximize federal protections from the PSO, patient safety culture topics, and much more!   Download the newsletter or view on Issuu.

Mixed results from Kentucky Supreme Court

The Kentucky Supreme Court has issued its anxiously awaited opinion in Tibbs, et al. v. Bunnell (2012-SC-000603-MR). The opinion is available online here. Earlier in the case, the Kentucky Court of Appeals ruled that only work reflecting “self-examining analysis,” could be protected PSWP, eliminating data or reports used as part of that analysis from protection. The hospital appealed, with support from the national PSO community. The Kentucky Supreme Court rejected that restriction based on the language of the law and final rule.   It went on to examine the definition of PSWP as applied to the information sought by the plaintiff, which included incident reports. (more…)

PSOs Are Watching New Florida Decison about PSWP

A Florida trial court order regarding the discovery of hospital incident reports is circulating in PSO circles.   (Charles v. Southern Baptist Hosp. et al., Duyal County, Case No. 15-2012-CA-002677.)   The order expresses a very restrictive view of PSWP (more below) and the hospital has expressed an intention to appeal the order.   As a trial court order in Florida, it has no value as precedent in any other jurisdiction, even within Florida.   However, the order will be part of the ongoing discussion about PSO protections, so CPS wants its stakeholders to understand it. The key facts:

  • Florida has very specific requirements for hospital risk management, including staff licensure and submission of certain incident reports to the state.   The statute also requires the hospital to gather information via incident reports that may not be reported to the state, but which is necessary to carry out the mandated activities.
  • The discovery request specifically asked for reports prepared pursuant to parts of the statute.
  • The court recognized the applicability of the Patient Safety Act and accepted that the hospital had a PSES and that the information was utilized appropriately in that context, and therefore would be protected PSWP except for the state risk management and reporting requirements.
  • The court found that the need to gather the information under state law and to report some of it precluded it from being protected PSWP. (more…)

Center Releases EMS-PSONews, Spring Edition

Click image to download or click HERE to view on ISSUU

EMS PSONews… a compilation of PSO topics specific to EMS

The latest EMS PSONews-Spring Edition includes articles and PSO information specific to EMS:

  • learning and sharing: defibrillation vs synchronized cardioversion
  • updates on EMS PSO activity
  • a legal update on Patient Safety Organization (PSO) protections,
  • highlights from the annual Agency for Healthcare Research & Quality meeting,
  • and much more!

Center releases Spring edition of PSO Newsletter

Click image to download or click HERE to view on ISSUU

The latest PSONews-Spring Edition includes:

  • a legal update on Patient Safety Organization (PSO) protections,
  • highlights from the annual Agency for Healthcare Research & Quality meeting,
  • coverage of the CPS WhitePaper on PSOs & ACOs,
  • a shared story with positive results from a policy aimed at managing aggressive behavior in the hospital,
  • and much more!

New Federal Court Opinion Applies PSQIA Protections Broadly

The District Court for the Western District of Kentucky has issued an incredibly helpful opinion for PSO’s and their participants.   (Tinal v. Norton Healthcare, No. 3:11-CV-596-S, May 8, 2014)   A copy of the opinion is available and a summary of the opinion by one of the law firms involved is also available.   The court reviewed the law and its history comprehensively.   Lawyers defending PSO participants should read it for guidance on how to approach PSWP protections.

The court noted that the statute uses “plain and unequivocal terms” to set out the privilege, and stated, “No ambiguity can be read into….the privilege statute.”   The plaintiff’s claim was for employment discrimination under the federal civil rights statutes, and she claimed that the PSQIA should only apply in medical malpractice cases.   The court disagreed, finding that “[w]e have no authority to go behind the plain meaning of the statute.”

(more…)

BLOG:

PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

Read More

RESOURCES:

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.