Safety in Numbers


Dr. Schwartz

Patient safety organizations, commonly referred to as PSOs, are about to take off. And when they do, PSOs should provide hospitalists with invaluable data on improving patient safety.

“PSOs are a great concept, but even though it’s been around since 2005, I haven’t seen it clinically,” says Janet Nagamine, RN, MD, hospitalist at Kaiser Permanente in Santa Clara, Calif., and chair of SHM’s Hospital Quality and Patient Safety Committee.

This calendar year, Nagamine and the rest of hospital medicine should start to see some movement—“PSO 1.0,” if you will.


PSOs are public and private organizations approved by the Agency for Healthcare Research and Quality (AHRQ); they include such groups as Health Watch Inc., Human Performance Technology Group, and the Institute for Safe Medication Practices, which will collect, aggregate, and analyze data on patient safety events. Hospitals and other healthcare providers will voluntarily and confidentially report data. The ultimate goal is to advance changes in culture, processes, and systems to enhance patient safety.

A hospitalist working in one hospital has only the information about events in that hospital, but 5,000 hospitals can provide more specific and actionable information.

PSOs grew out of the Patient Safety and Quality Improvement Act of 2005, which was a response to the Institute of Medicine’s landmark report “To Err Is Human: Building a Safer Health System.” But it wasn’t until last year that the U.S. Department of Health and Human Services issued a final rule outlining PSO requirements and procedures. The rule became effective Jan. 19, 2009.

AHRQ is responsible for coordinating the development of a set of common definitions and reporting formats, called common formats, for collecting the data. Eventually, AHRQ will create a network of patient safety databases to which PSOs, providers, and others can voluntarily contribute non-identifiable patient safety information. This network will serve as an interactive evidence-based management resource for providers, PSOs, and other entities. AHRQ will use data from the network to analyze national and regional statistics regarding patient safety events. Findings will be made public and will be included in AHRQ’s annual National Healthcare Quality Report.

Public Policy Points

Primary Care Matters

American primary care is critically important to providing patients with better outcomes at lower costs, as confirmed by a white paper released by the American College of Physicians (ACP). “How Is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?” reviews 20 years of research and documents the value of primary care. The white paper outlines more than 100 studies, providing an overview of current trends in the primary-care-physician workforce, the importance and value of primary care, and the growing demand for primary-care services in the U.S. Download the white paper.

Resident Duty Hours Reduced Again?

A report released by the Institute of Medicine (IOM) in December recommends further restrictions on resident duty hours. Although the report encourages sticking with the current 80-hour workweek, it suggests limiting residents to 16-hour shifts, including a mandatory five-hour sleep break, and providing continuous and immediate access to an in-house supervising physician. The recommendation even calls for providing transportation home in case a resident is too tired to drive safely. Read the report .

Pennsylvania Hospitals Sue for Malpractice Money

The Hospital and Health System Association of Pennsylvania filed a lawsuit Dec. 11 alleging the administration of Gov. Ed Rendell violated the state’s constitution by failing to provide funding for Mcare, a program designed to help subsidize medical malpractice insurance costs for doctors. The suit says the state owes doctors and other providers between $446 million and $616 million in reimbursements for bills paid into the malpractice fund. Funding for the Mcare program comes from a state tobacco tax. The suit requests Mcare be fully funded by the state; Gov. Rendell has stated he would not reinstate full funding until the legislature acts on his proposal to expand affordable health coverage to more state residents.

IT Example

To date, the only comparable data-collection system is MedMarx, which compiles information on medication errors. The Joint Commission requires providers to supply a root-cause analysis on every Level 1 incident, “but that’s just scratching the surface of what occurs,” Dr. Nagamine says. “There are far many more Level 2 and Level 3 events with the same precursors, and that information would be very valuable.”

By collecting nationwide data on patient safety events, PSOs will be able to bridge the gaps in the reporting system and provide crucial patient safety information to the healthcare industry. “In general, the concept of aggregate information that allows us to compare events is incredibly important,” Dr. Nagamine says. “A hospitalist working in one hospital has only the information about events in that hospital, but 5,000 hospitals can provide more specific and actionable information. We just haven’t seen this operationalized yet.”

Dr. Nagamine uses a technology example to show the value PSOs could have in identifying patterns or problems that threaten patient safety: “Every hospital has a horror story of implementing a new information technology (IT) system, and we’re getting some very interesting feedback from hospitals about unintended consequences,” she says. “We’re hearing that patients are being hurt because of mistakes in systems—the use of dropdown menus (on computer screens) that don’t drop down far enough to reveal all options, or a screen where it’s easy to click the wrong item.”

Current systems might not allow problems like these to be highlighted. Even if staff knows of a problem, their hospital’s coding system might not allow them to detail it. “It may fall under ‘communications’ or ‘physician computerized order entry’ or something vague, so the data won’t show the specifics of what happened,” Dr. Nagamine points out. “If we had aggregate data on issues like this, we could address it. Right now, we just have word of mouth.”

An isolated event at a hospital is one thing, but similar data from around the nation is significant. “Drug companies or IT vendors confronted with (patterns) might make some changes,” she says. “That kind of data is powerful.”

Hospital Medicine on Board

When hospitals start reporting data to PSOs, where will hospitalists fit into the process? Hospitalists likely will be interviewed to answer some of the PSO’s questions, but they will not be the ones filling out the forms, Dr. Nagamine says. Hospitalists also will be among the ranks of healthcare professionals eagerly awaiting the release of the data. “The way that PSOs approach patient safety and quality—what’s near and dear to our hearts—is it gives us more data,” Dr. Nagamine says. This is crucial for hospitalists leading quality-improvement projects and similar tasks. “Without that data, it’s hard to get traction and movement. That data will help convince someone to invest more time and money in a particular problem area.”

Phase One: Participation

AHRQ has established a comprehensive Web site ( that includes information on the first draft of common formats for use with hospital inpatients. These are found on downloadable paper forms, available at the PSO Privacy Protection Center (PPC) Web site at web/patientsafety/paperforms.

“The forms are a first step,” Dr. Nagamine explains. “If we had these data points on every incident at every hospital, we’d know a lot more than we do now. We’d be able to harness that information.”

It will be a while before healthcare providers can search the data for patterns and possible solutions in patient safety, but the wait should be worth it. “You’ve got to start somewhere, and it’s not going to happen in one sweep,” Dr. Nagamine says. “This is simply a start. Hopefully, in a decade, we’ll have a lot more actionable information.” TH

Jane Jerrard is a medical writer based in Chicago.

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