Situation:
The nation was shocked by an Institute of Medicine report that noted that medical errors are the eighth leading cause of death in the United States, with as many as 98,000 deaths per year. In response to such concern, President Bush signed the Patient Safety and Quality Improvement Act of 2005, Public Law No. 109-41 (the “Act”), which creates a voluntary system for health care providers to confidentially report medical errors and other patient safety information to Patient Safety Organizations (PSOs). The PSOs aggregate and analyze the reported information in order to develop strategies to improve patient safety.
Under the Act, the Federal Department of Health and Human Services certifies as PSOs both public and private entities focused on improving patient safety and the quality of health care. Certified PSOs enter contracts with health care providers to collect their reports and use the information to provide direct feedback and assistance in order to minimize risks to patients. The information is aggregated in a network of patient safety databases that provide an interactive, evidence-based management resource for both providers and PSOs. Reports to PSOs are permitted from any entity licensed under state law (i.e. hospitals, long term care facilities, home health agencies, pharmacies, physician’s offices and clinical labs) to provide health care services.
Reported information is confidential and privileged under the Patient Safety and Quality Improvement Act, so adverse employment action cannot be taken against an individual for good faith reporting to a patient safety organization. Further, accrediting bodies may not take an accreditation action against a provider based on the provider’s good faith participation in reporting and cannot require a provider to reveal its communications with any PSO.
Solution:
Global Compliance provides incident reporting solutions including hotline and Web access for intake of patient safety data from hospitals and other health care providers. Received data is housed in a centralized repository enabling efficient data transfer to PSOs. Query, analysis and trending of patient safety reports help to identify repetitive incidents that must be addressed in order to prevent future occurrences.
Outcome:
While participation with the new Patient Safety and Quality Improvement Act is voluntary, health care organizations proactively participating will increase their quality of care making them more valuable and profitable in the long term. Further, the implementation of an Incident Reporting program will protect the organization and individual reporting parties, thus fostering a more inclusive culture of patient safety.
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