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Patient Safety Organization

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*:

  • Fear of disclosure:
    Physicians and other 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.

To address these issues, independent, federally certified patient safety organizations (PSOs) were created through the federal Patient Safety & Quality Improvement Act of 2005. Based on the Federal Aviation Administration model of nonpunitive near-miss reporting, the mission of PSOs is to engage in data collection activities that enable participating hospitals to work together, and ultimately, continue to create cultures of increased patient safety.

Organizations that are eligible to become PSOs include: public or private entities, profit or not-for-profit entities, provider entities such as hospital chains and other entities that establish special components to serve as PSOs. By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and healthcare organizations can collect, aggregate and analyze data that enable the identification and reduction of risks and hazards associated with patient care.

Additional Resources

*From the Agency for Healthcare Research and Quality

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