Taking away the fear: Another step toward improving patient safety

The final rules of the Patient Safety and Quality Improvement Act ensure that physicians have a safe resource to discover ways to improve the way they practice.

Posted Jan. 26, 2009.

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Part of advancing patient safety is giving physicians opportunities to learn from treatment errors that have occurred. But in an environment where admitting a mistake can lead to a knock on the door from a trial lawyer, physicians would be right to be wary of what might happen if they willingly open up themselves for scrutiny.

Fortunately, a program is now in place that would allow doctors to share information about what they can do better for patient safety without fear of punitive action.

On Jan. 19, the final rules went into effect regarding the Patient Safety and Quality Improvement Act of 2005, which the American Medical Association was integral in championing. The act gives physicians a chance to submit information about patient safety issues in a way that is confidential, nonpunitive and voluntary. It will improve patient safety by encouraging doctors to open up about errors, near-misses or other concerns in a forum where they don't have to worry about a trial lawyer going after them for what they have shared.

While Congress passed the act, and the Dept. of Health and Human Services and its Agency for Healthcare and Research Quality were responsible for setting up its rules, the government is not involved in collecting and disseminating data. That is left to AHRQ-certified patient safety organizations, or PSOs, private organizations with which physicians can consult. As PSOs collect information, they will share it with a Network of Patient Safety Databases, which will then be able to offer de-identified and aggregate patient safety information to any doctor who wishes to use it as a means to reduce the risk of adverse events.

Physicians may submit patient safety deliberations, analyses and peer reviews and other patient safety work products without being subject to legal discovery. However, that protection does not apply to medical and billing records normally kept outside safety reporting systems, nor does it affect state medical error reporting requirements.

But the PSOs are not a mandatory error-reporting system. Physicians aren't required to submit information to a PSO if an error occurs, nor are they limited to submitting information only if one did. Rules are in place as to how a PSO may combine data and spot error trends. The point is to provide an innovative physician- and provider-driven system to advance patient safety.

Right now, the systems initially being set up are focused on hospital event reporting. It's expected that in about two years PSOs will be set up for ambulatory events as well. As of mid-January, 39 PSOs were in place, ready to accept information. Many more will come. The list of AHRQ-approved PSOs is available online (link).

As this patient safety effort grows from this early stage, the AMA and others will work to inform physicians about how the PSO process works, and how physicians can choose the right PSO. Because the PSO system is a private one, physicians would have to contract with a PSO and might have to pay a fee for its analysis. (The fee varies by PSO and is not set by HHS.)

Many institutions and practices are likely to find it worth paying, given how PSOs can give physicians more knowledge about patient safety. And that information will be gathered in a productive way, one in which physicians will not be punished for reporting and questioning what could have been done better to treat patients.

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