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Collaborative Program Looks to Prevent Errors Through Data Sharing

Heather Comak, May 6, 2009

Four years after the Patient Safety and Quality Improvement Act of 2005 authorized the creation of Patient Safety Organizations (PSO), hospitals can now join a PSO of their choice. Ultimately, what this provides hospitals around the country is a chance to receive stronger data analysis and solutions surrounding quality- and patient safety-related errors, enabling them to create better systems for patient care.

Many hospitals already have event reporting systems, allowing data analysis at a hospital or hospital system level to occur, and some states also have reporting systems. But PSOs allow for data aggregation and trending to occur at a broader level.

"Once PSOs receive [patient safety work product (PSWP)], it's not just holding it, but really beginning to do some analysis and providing information back to the hospital or provider so that they can use the information to implement new solutions," says Amy Helwig, MD, MS, medical officer at the Agency for Healthcare Research and Quality (AHRQ), which oversees the PSO system. "The PSO can provide the expertise in looking at different types of patient safety event information and help guide the hospital."

The final rule, which was issued November 21, 2008, and went into effect January 19, 2009, stipulates which types of organizations can become PSOs and details the system that must be set up between the PSO and the facilities with which it has contracted. Those hospitals and hospital systems that have contracts with PSOs can provide data to PSOs in the form of PSWP. Data considered PSWP must be identified as such by the facility.

PSWP can be collected or translated by a hospital or PSO into what the AHRQ has termed "Common Formats" so that all data a PSO receives are standardized and can be easily compared.

Those data can then be aggregated, analyzed, and sent back to the provider. In addition, if the data are made nonidentifiable, they can be sent to the Network of Patient Safety Databases, a central location where PSOs around the country will share data. PSOs supply analyzed data and solutions to individual providers based on their own data, as well as the pool of data shared across organizations with which the PSO has contracted.

Data protections offer many benefits
In addition to aggregation of PSWP, the PSO system affords PSWP certain protections. These legal protections allow any adverse event–related data identified by providers as PSWP to be sent to a PSO, making the data flow confidential. These protections were set up to encourage organizations to share data from more serious events and near misses so the industry as a whole can benefit, says Helwig. The Office for Civil Rights is responsible for enforcing the final rule.

One of the things that has prevented this data flow in the past was the lack of protections given to data surrounding adverse events, says Ken Rohde, senior consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, which has partnered with Peminic, Inc., to create the Peminic-Greeley PSO.

"People from one hospital were not real comfortable sharing their problems with people from another hospital because of the risk of liability, discovery, and litigation," says Rohde. "As part of the PSO process, there is increased confidentiality and protection of the data to help facilitate people's willingness to share the data, and once we share that data and aggregate it, it reduces our cost of learning. This approach is really not new; many other industries, even competitive industries, have shared their occurrences and problems in order to help them move forward more effectively."

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