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AHRQ Patient Safety Organizations Home Page
Maine Patient Safety Organization Network
Current Activity and Recent Developments
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Patient
Safety Organizations
The
Patient Safety and Quality Improvement Act of
2005 (Public Law 109-41), signed into law on July
29, 2005, was enacted in response to growing concern
about patient safety in the United States and
the Institute of Medicine's 1999 report,To Err
is Human: Building a Safer Health System.
The
goal of the Act is to improve patient safety by
encouraging voluntary and confidential reporting
of events that adversely affect patients.1
The
Patient Safety and Quality Improvement Act signifies the Federal
Government's commitment to fostering a culture of patient safety.
It creates Patient Safety Organizations (PSOs) to collect, aggregate,
and analyze confidential information reported by health care providers.
Currently, patient safety improvement efforts are hampered by
the fear of discovery of peer deliberations, resulting in under-reporting
of events and an inability to aggregate sufficient patient safety
event data for analysis. By analyzing patient safety event information,
PSOs will be able to identify patterns of failures and propose
measures to eliminate patient safety risks and hazards.
Many
providers fear that patient safety event reports could be
used against them in medical malpractice cases or in disciplinary
proceedings. The Act addresses these fears by providing
Federal legal privilege and confidentiality protections
to information that is assembled and reported by providers
to a PSO or developed by a PSO ("patient safety work
product") for the conduct of patient safety activities.
The Act also significantly limits the use of this information
in criminal, civil, and administrative proceedings. The
Act includes provisions for monetary penalties for violations
of confidentiality or privilege protections.
Additionally,
the Act specifies the role of PSOs and defines "patient
safety work product" and "patient safety evaluation
systems," which focus on how patient safety event information
is collected, developed, analyzed, and maintained. In addition,
the Act has specific requirements for PSOs, such as:
PSOs are required to work with more than one provider.
Eligible organizations include public or private
entities, profit or not-for-profit entities,
provider entities, such as hospital chains,
and other entities that establish special components.
Ineligible organizations include insurance companies
or their affiliates.
Finally,
the Act calls for the establishment of a Network
of Patient Safety Databases (NPSD) to provide
an interactive, evidence-based management resource
for providers, PSOs, and other entities. It will
be used to analyze national and regional statistics,
including trends and patterns of patient safety
events. The NPSD will employ common formats (definitions,
data elements, and so on) and will promote interoperability
among reporting systems. The Department of Health
and Human Services will provide technical assistance
to PSOs.1
1The Patient Safety
and Quality Improvement Act of 2005. Retrieved
from http://www.ahrq.gov/qual/psoact.htm
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