Publications & White Papers


Improving Patient Safety: The Intersection of Safety Culture, Clinician and Staff Support, and Patient Safety Organizations (2015)
By: Rebecca G. Miller, MHA, FACHE, CPHQ, CPPS; Susan D. Scott, RN, PhD, CPPS;
Laura E. Hirschinger, RN, MSN, AHN-BC

Staci Walters, RN, MSN, CNL, CPPS; Nancy Schanz, RN, MA, MHA, MBA; Celeste Mayer, RN, PhD

Abstract: Lessons from high reliability industries such as nuclear power and aviation are being adopted in healthcare. A key component of a high reliability organization is a culture of safety that relies upon trust, report and improvement. (Reason and Hobbs, 2003).

One initiative gaining considerable recognition in promoting trust and providing clinician support is a Second Victim Intervention Program. This kind of intervention offers peer support to individual healthcare workers and professionals who are involved in, or victimized and traumatized by, an unanticipated adverse patient event, medical error, or a patient related injury. (MU Health forYOU Team).

Second Victim Intervention Programs demonstrate respect of healthcare workers and an appreciation of the complexity and risk inherent in the healthcare work environment. Additionally, Second Victim Intervention Programs compliment patient safety program activities that assess culture, identify and report adverse events, disclose errors, support patients and families, and take action to reduce repeated errors.
As pioneers of the Second Victim movement, MU Health patient safety researchers established the forYOU Team in 2007. Through a structured system of training, support, documentation and integration with the patient safety program, a dedicated team of frontline peer supporters serve as rapid responders who identify and support second victims. Having supported more than 1,360 second victims, the forYOU Team’s success continues building on trust that enables staff to seek help and healing.

Confidentiality, a critical success factor for a Second Victim Intervention Program, must be ensured for peer supporters and second victims. An organization establishing a program and participating in a federally-designated Patient Safety Organization (PSO) can define the program within its Patient Safety Evaluation System (PSES). It can also define program documentation as Patient Safety Work Product (PSWP) to obtain federal level confidentiality protections available through the Patient Safety and Quality Improvement Act of 2005 (PSQIA).

Opportunities to implement and integrate a Second Victim Intervention Program within an organization’s PSES through PSO participation (and next steps) are discussed within this paper.

PSOs: Essential to ACO Success (2014)
By: Susan Kendig, JD, MSN, WHNP-BC, FAANP & Rebecca G. Miller, MHA, CPHQ, FACHE, CPPS

Abstract: As health care responds to the imperative to improve quality and efficiency, a variety of business models featuring a clinically integrated approach to care and alternate payment methods are under consideration. Even before passage of the Patient Protection and Affordable Care Act (PPACA) in March 2010, there was increased interest in the development of different care delivery and payment models as mechanisms to transform health care through better alignment of financial incentives for providers with quality and cost goals. Prior legislation had already moved the Centers for Medicare and Medicaid Services (CMS) from a passive purchaser of volume-based health care to an active purchaser of value-based, high quality health care, targeting quality and efficiency improvements through payment reform.

Patient Safety Organizations and Transparency: Working together to improve patient safety (2012)
By: Susan Kendig, JD, MSN, WHNP-BC, FAANP & Rebecca G. Miller, MHA, CPHQ, FACHE, CPPS

Abstract: The Institute of Medicine's (IOM) landmark report, To Err is Human, 1 estimated that 98,000 deaths occur annually due to medical errors in the United States. This report generated a renewed national interest in adverse events in health care. Transparency, the free, uninhibited sharing of information, is fundamental to reversing this trend and achieving meaningful health care quality and patient safety improvements.  Yet, factors such as fear of litigation or adverse professional consequences, embarrassment, misinterpretation of what constitutes harm, disbelief that reporting will lead to improvement, and time required to report hinder transparency efforts. Recognizing that medical errors are usually the result of system errors rather than individual carelessness, public reporting of quality data, root cause analyses, mortality morbidity review processes, and Patient Safety Organizations (PSOs) have emerged as mechanisms to support information sharing and replace the culture of blaming health care professionals with an organizational culture of safety.

In response to the IOM report and concern about growing malpractice costs, a sixteen member Missouri Commission on Patient Safety was appointed in 2003 to study the issue and recommend actions to improve patient safety and prevent medical errors in Missouri.  The Commission determined that patient safety activities were fragmented, conducted in isolation, and could not provide an accurate picture of adverse events in the state. Given the lack of a focal point to coordinate patient safety work, the Commission recommended the creation of a private Missouri Center for Patient Safety (the Center) to provide leadership for patient safety improvements including serving as a federally designated Patient Safety Organization (PSO), should proposed federal legislation to establish PSOs be signed into law. This action positioned Missouri at the forefront of the patient safety movement in developing a coordinated system to perform patient safety activities and disseminate learnings. The Center opened in 2005, and in 2008 became one of the first ten entities in the country to meet requirements for federal listing as a PSO.

This paper provides a brief overview of the legal protections available to health care providers that participate in a PSO, discusses the PSO framework as it relates to transparency efforts, and describes how the PSO protections can work synergistically with other reporting mechanisms, including transparency efforts, to achieve safety and quality improvements.



Using Advanced Technology to Pursue Quality & Best Practices
By: Allison J. Bloom, Esq. & Lee Varner, BS EMS, EMT-P| May 2015 | EMS Insider

Program Brief, National Patient Safety Database (NPSD), PSOs: A Summary of 2013 Profiles
By: AHRQ Pub. No. 15-0013-EF | January 2015 | AHRQ

Influencing Leadership Perceptions of Patient Safety Through Just Culture Training
By: Scott Griffith, MS; Becky Miller, MHA, CPHQ, FACHE; Jill Scott-Cawiezell, PhD, RN, FAAN; Amy Vogelsmeier, PhD, RN, BC-GCNS | October-December 2010 - Volume 25 - Issue 4 - p288-294 | Journal of Nursing Care Quality

Abstract: There are differences in perceptions of safety culture between healthcare leaders and staff. Evidence suggests that an organization's actual safety performance is more closely reflected in staff perceptions suggesting that frontline staff may be more aware than the leadership of actual patient safety challenges within their organization. Closing the perception gap between healthcare leaders and staff is critical to aligning the resources and strategies required to create a true culture of safety.

A Statewide Approach to a Just Culture for Patient Safety: The Missouri Story
By: Becky Miller, MHA, CPHQ, FACHE; Amy Vogelsmeier, PhD, RN, BC-GCNS | Journal of Nursing Regulation

Building a PSO Field of Dreams
By: Carol Hafley, MHA, BSN, RN | Patient Safety & Quality Healthcare

Not just for show | Missouri's safety efforts preceded IOM report, continue quietly today
By: Becky Miller; Herb Kuhn; C.C. "Cork" Swarens; Richard Royer | November 2009 | Modern Healthcare Magazine

Prevention Strategist - Justice For All
By: Carol Latter | Winter 2009 | Prevention Strategist

Walking the Punitive/Blame-Free Tightrope
By: Becky Miller, MHA, CPHQ, FACHE, Executive Director, Missouri Center for Patient Safety; Revee Booth, BJ, Communication Specialist, Primaris  | Spring 2008 | Missouri Primary Physician

The Patient Safety and Quality Improvement Act of 2005 - The Federal Law and its Implications for Missouri
By: Becky Miller, MHA, CPHQ, CHE; Jennifer L. Druckman, JD, MHA, RHIA | January/February 2007 | Missouri Medicine

Find more information in the Center’s annual reports and newsletters.


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

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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.