Patient Safety Organizations*
In 1999, the Institute of Medicine (IOM) issued a landmark report entitled, “To Err is Human: Building a Safer Health System,” which highlighted critical areas of research and activities needed to improve the safety and quality of health care delivery. One critical area of the IOM report addressed the reporting and analysis of data on adverse events.
The IOM report and its findings spotlighted a serious need to capture data that would help to reduce harm to patients. Addressing this need, Congress passed The Patient Safety and Quality Improvement Act of 2005 Patient Safety Act. The Patient Safety Act authorizes the creation of Patient Safety Organizations (PSOs) to improve safety and quality through the collection and analysis of data on patient events.
events and PSWP used to
reduce risk and improve
safe care delivery
Background*
Clinicians and other people interested in patient
safety may wonder what led to the creation of
Patient Safety Organizations (PSOs). To answer
this question, it is helpful to look to the past.
In the past, individual facilities and states have
encouraged clinicians to report patient safety
events. However, two major impediments have
stood in the way of collecting enough
representative data to make significant
improvement:
*Source: Agency for Healthcare Research and Quality
clinicians traditionally have been reluctant to
participate in peer review of patient safety events for fear of legal liability, professional sanctions, or injury to their reputations.
Isolated data: Patient safety event reports
traditionally have not been standardized to allow
aggregation of data and sharing across different
institutions. An insufficient number of reports
have made it difficult to identify and mitigate
underlying patterns of causal factors.