Experts say PSOs will improve patient safety in U.S. hospitals

By assuring privacy, more data on errors likely to be collected

Experts in quality improvement say that the recent listing of the first 15 patient safety organizations (PSOs) under the Patient Safety and Quality Improvement Act of 2005 will help hospitals across the United States improve patient safety by enabling the establishment of a huge database on errors and what causes them.

Although several of the organizations have been in operation for a number of years, they tell Healthcare Benchmarks and Quality Improvement that the voluntary sharing of data by hospitals in their area has not been as widespread as they had hoped due to fears that the data would not be kept confidential. The Agency for Healthcare Research and Quality (AHRQ), which administers the Patient Safety and Quality Improvement Act, assures on its web site that the data collection activities under the act will provide "both privilege and confidentiality."

The new PSOs are:

  • California Hospital Patient Safety Organization, part of the California Hospital Association and California Association of Hospitals and Health Systems;
  • Clarity PSO;
  • ECRI Institute PSO;
  • Florida Patient Safety Corp.;
  • Health Watch Inc.;
  • Human Performance Technology Group;
  • Institute for Safe Medication Practices;
  • Missouri Center for Patient Safety;
  • Peminic Inc.;
  • Quantros Patient Safety Center;
  • Sprixx;
  • Texas Patient Safety Organization Inc.;
  • the Patient Safety Group LLC;
  • the University Healthsystem Consortium (UHC).

What is a PSO?

William B Munier, MD, AHRQ's director, Center for Quality Improvement and Patient Safety, explains what a PSO is and what qualifies an organization to become a PSO. "The Patient Safety Act permits any entity — an entire organization or a component of an organization, a public or private entity, a for-profit or not-for-profit entity — to seek listing as a PSO," he says. "There is an exception, however, which is that a health insurer, or component of a health insurer, may not be a PSO."

While the organizations that seek listing as PSOs may "look" different, he continues, all PSOs will share a common goal of improving the safety and quality of health care delivery. "By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data that enable the identification and reduction of the risks and hazards associated with patient care," he says.

PSOs are designed to improve the quality and safety of U.S. health care by encouraging clinicians and health care organizations to report and voluntarily share data on patient safety events without fear of legal discovery, Munier explains. "PSOs are intended to help remove the barriers — the fear of legal liability or sanctions — that clinicians and health care organizations currently face related to patient safety event reporting and quality improvement," he says.

"PSOs will be a source of confidential and privileged external advice for health care providers seeking to understand and minimize the risks and hazards in delivering patient care. Furthermore, PSOs serve as a mechanism for aggregating sufficient numbers of patient safety events so that the underlying causes of patient harm and poor quality can more quickly be identified and addressed and lessons learned can be shared broadly."

Past may be prologue

Since many of these organizations have already been working with hospitals to improve patient safety, a closer look at a few of them can provide some insight into the benefits other hospitals could reap if they chose to participate in the program.

For example, the University Healthsystem Consortium, or UHC, in Oakbrook, IL, has created the UHC Patient Safety Net, a web-based, real-time patient safety event reporting tool, which is already in use in 68 academic medical centers and their affiliated community hospitals.

"It allows organizations to enter information on events," says Wanda Clevenger, RN, BSN, MBA, director of the UHC Patient Safety Net. "What makes it unique is that it has two levels of users. One is the anonymous' level, available to any employee of a hospital or health center using it; they do not need a login or a password. Then, there is the authenticated user."

Both can enter an event, she explains, but an authenticated user is a manager who also reviews and comments on the event, noting contributing factors and systems issues surrounding the situation.

Another unique aspect of the consortium, says Clevenger, is that all participating organizations have agreed to use common taxonomy. "This gives us the ability to compare data," she says. "This is something the PSO will be doing so we can compare apples to apples.'"

The tool can be used in a number of ways. For example, says Clevenger, she might get a call from a quality manager to look at issues involving radiology contrast problems. "We'd pull all the events in aggregate, look at contributing factors, best practices, and prepare a study," she explains. "This helps member organizations understand how these events happen, then look at their own policies and procedures and perhaps make changes.

"We found that with each study done we incorporated the information into the tool going forward," Clevenger continues. "Then, participants may ask additional questions. So, in the example of radiology extravasation (when dye is injected outside the vein), we could help them look for what impacts such errors — how long the IV had been in place, did they use a pump when injecting the dye, and so forth. When we have a larger database, we will be able to determine the most common reasons for those errors."

Which is not to say that UHC hasn't already gotten to the bottom of some vexing issues; for example, notes Clevenger, there is an event category the organization calls "delay in treatment."

"Participants had identified a high rate of delays in radiology," she notes. "When we looked at what happened, the staff thought the papers were all being faxed to the radiology department, but the organization did not have a preset phone number. They were being mis-faxed, and radiology never received them. So they have now preset all clinical areas to the radiology department — kind of like a speed dial — and things are no longer getting lost."

UHC currently is reviewing events involving epidural IV mix-ups, says Clevenger. "When we collected information, we ask the frontline reporter what happened and for recommendations around improvement," she notes. "We found in a number of events that it would be helpful if the epidural lines had different connectors." UHC, she adds, is currently investigating connector options.

In 2009, says Clevenger, UHC will be using its aggregate data to examine organization culture of safety, national safety initiatives, anti-coagulation, and fall prevention.

Clevenger believes the PSO designation will encourage even more facilities to participate. "One of the reasons why organizations were hesitant to join is because we always had this philosophy of sharing the data," she explains. "This PSO designation will give those organizations more of a comfort level because their information will be protected; it will not be discoverable by an attorney."

Excited' about status

Becky Miller, MHA, CPHQ, FACHE, executive director of the Missouri Center for Patient Safety in Jefferson City, says she is "excited" to be a PSO because "we did not have any protection. Therefore, we've not been able to answer questions about what errors happened and why."

The organization has been active in patient safety in other areas, however. For example, says Miller, "We sponsored a project called Banding Together for Patient Safety' that helped hospitals in the state standardize the use of colored wristbands [to indicate certain patient conditions, such as DNR status]. We also got some grant funding for a statewide collaborative on a just culture. And we've been holding annual conferences that have been well attended, and serve as a resource on patient safety."

Going forward, however, she expects to be able to "really work with hospitals to identify what errors need to be reported, what is most meaningful to them, and to have the data and information about what errors happened, what caused them, and how we can work together to provide a prevention strategy. Until we got the ability to start collecting it, we have not had the data to support which direction we need to go in."

Looking ahead, Miller says, "I can envision us actually using some of the work groups we already have in place, which include representatives from hospitals across the states, to focus on what we can learn about our most prevalent errors, then bring experts to the table, help us drill down to the cause then, and do a clinical collaborative on what we've learned, and develop educational programs around those issues."

A lifesaver' for organization

For the Florida Patient Safety Corp. in Tallahassee, its PSO designation may actually be the key to its survival. Founded in 2004 by the Florida legislature, it lost its state funding about two years ago. Now, with its new designation, it is seeking private support by asking participating facilities and physician practices to pay membership fees.

As of this writing, the organization was planning to launch its marketing campaign at the beginning of 2009, according to Susan Moore, CEO. "We will market not just to hospitals, but to surgicenters and large physician practices," she says. "They will pay for a product. We will be selling a product and will be putting out reports like we did before."

In the early years, she explains, the organization was able to collect data and created a near-miss recording system. "We put out several reports, but we had to stop doing it because we faced a huge budget crunch," she says.

[For more information, contact:

Wanda Clevenger, RN, BSN, MBA, Director, UHC Patient Safety Net, Oakbrook, IL. Phone: (630) 954-2808.

Becky Miller, MHA, CPHQ, FACHE, Executive Director, Missouri Center for Patient Safety, 2422 Hyde Park Road, Suite B, Jefferson City, MO 65109. Phone: (573) 636-1014, ext. 225. Fax: (573) 636-8608. Toll-free: (888) 935-8272. Email:

Susan Moore, CEO, Florida Patient Safety Corp., 2722 Waterford Glen Court, Tallahassee, FL 32312. Phone: (850) 893-8936. Fax: (850) 893-4259.]