Rory Jaffe rjaffe at CHPSO.ORG
Tue Mar 27 22:48:42 UTC 2018

While that is not all PSOs were set up to do that is certainly one use. PSOs were set up to serve many needs and provide many different services.

To Err is Human noted that it is not human nature to share information and be completely self-critical without protections from discovery and adverse consequences (e.g., litigation, adverse publicity). The authors also noted that that must be balanced with public accountability. Among its recommendations, the publication proposed two reporting systems:

  1.  Mandatory reporting of serious events to the state, for accountability
  2.  Voluntary confidential reporting, for learning at the aggregate level and spread of information from individual lessons learned as well as spread of aggregate knowledge.
The publication also recommended privilege and confidentiality protection for quality improvement work product just as there is for peer review product in most states. And note that non-hospital providers in most states do not have access to peer review privilege, hampering self-critical reviews.

Congress rolled all this up into the law establishing PSOs. Organizations that participate with a PSO provide safety information to the PSO, and gain certain privilege and confidentiality protections (the limitations are too complex to discuss here) for the information submitted as well as the deliberations and analysis around the information. PSOs have mandated activities, many of which involve these submitted materials, including:

  1.  Collection and analysis of information from providers
  2.  Development and dissemination of information with respect to improving patient safety, such as recommendations, protocols, etc.
  3.  Using submitted information for encouraging a safety culture
  4.  Providing feedback to participants, including assistance to minimize patient risk

So, PSOs do a lot of things, and it varies by PSO.

CHPSO, for example, collects reports of incidents, near misses, and unsafe conditions. We have about 1.6 million so far. We mine through those in several different ways—both quantitative (e.g., correlation between certain drugs and reported harm level) and qualitative (e.g., pulling a set of related events due to concerns about a potential issue that was detected either by a report by a member or by an environment scan—such as info in the MAUDE device database. We put out a newsletter, patient safety alerts, and have very frequent phone meetings (22+/year) at which our members can have a frank discussion and shared learning about a specific issue—last one was on med rec. We also provide provider-specific feedback in a number of ways.

CHPSO also critiques RCAs (though I hate the term Root Cause), providing feedback and disseminating lessons learned. This is at a much much lower volume than incident reports for several reasons: there isn’t a standardized taxonomy for RCAs, most RCAs are documented in a way that mapping to a standard taxonomy would be tedious (not much structured data in most providers’ event analysis systems), RCAs are conducted for only a few events, and much of what we learn comes from the wider view of how systems work that we get from reading many events rather than a single RCA (again, partly because RCAs tend to look for a “root cause”, are specific to the event, and often miss the forest for the tree).

We also intervene at the national and international level for our members to improve the design of devices and medication packaging, as we have found that many of the safety problems are, at least in part, due to the lack of proper design of such things as EHRs, infusion pumps, etc. Manufacturers do not really respond to concerns from individual organizations, but our aggregate view helps.

Some PSOs are more like registries, and collect information on each patient meeting a criterion and provide aggregation and analysis for that. And others do data mining through the provider’s data systems for trends and discoveries. A number of medical specialties have formed PSOs, and some of those have a focus on diagnosis—particularly ones that serve diagnostic specialties such as pathology.

Rory Jaffe, MD MBA, Executive Director, CHPSO<http://www.chpso.org/> Patient Safety Organization
1215 K Street, Suite 930
Sacramento, CA 95814
rjaffe at chpso.org<mailto:rjaffe at chpso.org>
(916) 552-2600


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From: David Meyers <dm0015 at ICLOUD.COM<mailto:dm0015 at ICLOUD.COM>>
Sent: Tuesday, March 27, 2018 7:25 AM
Subject: [No SPF Record] [IMPROVEDX] PSOs

From: Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>>

An effective RCA 'system' would incorporate such information into an RCA Knowledge base that could be used for such leveraged learning and education.  I thought the PSO's (Patient Safety Organizations) were set up to:

1.       create a safe haven for such sensitive RCA data (protect from discovery), and

2.       provide QA/QC reviews on the quality of RCA inputs and outputs, and

3.       construct and compile meaningful data from RCA's for the purposes of tracking and trending across the country.

Am I incorrect in my understanding of the role of a PSO?



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