Patient Safety Organizations (PSOs) are a vital tool for healthcare organizations that enable you to improve medication safety and focus on quality improvement work in a safe, legally-protected environment.

Medication errors are an unfortunate occurrence in pharmacies, hospitals, long-term care and other healthcare settings across the United States, and the impact they have is devastating. Between 7,000 and 9,000 people die every year as a result of medication errors, and hundreds of thousands more are harmed or experience adverse reactions and complications. The financial impact is also staggering – the cost of caring for patients who experience medication-related errors exceeds $40 billion annually, with over 7 million patients impacted.

And with the population aging, risk will only continue to increase. By 2040, one in five Americans will be 65 or older, and nearly half will take five or more prescription medications daily.

How can you limit the risk of patient harm in your healthcare organization? Join a Patient Safety Organization.

While medication errors will never be completely avoidable, joining a Patient Safety Organization (PSO) enables your organization to review medication errors and focus on enhancing your continuous quality improvement work in a safe, legally-protected environment. 


What are Patient Safety Organizations?

A Patient Safety Organization is an entity or a component of another organization (private or public) that has a mission and primary activity of improving patient safety and the quality of healthcare delivery. PSOs can legally receive confidential healthcare information from members, review it, and provide objective analysis and advice on how to make improvements. PSOs can also aggregate healthcare information and provide advice to all members on an anonymized basis. To be valid, a PSO must be certified by the Agency for Healthcare Research and Quality and listed on their website.

All federally-listed PSOs are required to perform eight patient safety activities:

  1. Improve patient safety and the quality of healthcare delivery
  2. Collect and analyze Patient Safety Work Product (PSWP)
  3. Develop and disseminate information regarding patient safety
  4. Utilize PSWP for the purposes of encouraging a culture of safety as well as providing feedback and assistance to effectively minimize patient risk
  5. Maintain procedures to preserve confidentiality with respect to PSWP
  6. Provide appropriate security measures with respect to PSWP
  7. Utilize qualified medical personnel
  8. Operate a patient safety evaluation system and provide feedback to participants in a patient safety evaluation system


How Can a Patient Safety Organization Benefit You?

In many healthcare settings, medication errors are not reported by staff due to fears of consequences. Too often, employees choose to hide their mistakes to avoid disciplinary action, which can result in further patient harm if an issue is not identified and fixed. Healthcare organizations are also typically hesitant to admit to errors or near-miss events over fears of lawsuits.

PSOs help establish trust and transparency by providing a safe space to report medication errors or near-miss events without the fear of retaliation, litigation, or disciplinary action. With PSOs, certain patient safety improvement activities and information can be protected from legal discovery (minus a few exceptions including malicious intent or criminal behaviours), and is not admissible as evidence. Privileges and confidentiality of any patient safety work performed in the PSO can never be waived. With these protections, staff and healthcare organizations can feel safe and comfortable honestly and accurately reporting errors and near-miss events. This encourages a ‘just culture’, where errors can be appropriately evaluated and discussed with a goal of finding a resolution, not assigning blame. Open, transparent communication helps ensure process gaps are more quickly identified and proactively addressed, and enables you to better evaluate the effectiveness of your continuous quality improvement (CQI) initiatives. 

As more process gaps are identified and fixed, it becomes harder for staff to accidentally commit avoidable errors, strengthening patient safety across your organization.

PSOs also benefit your organization by:

  • Standardizing data collection and reporting for trending and analysis among providers. Standardization enables PSO members to quickly identify trends and look for clusters in events that might indicate a process gap.
  • Full array of activities to develop insight into the underlying causes of harm and improve patient safety. Insights enable you to pinpoint problems faster to proactively make improvements.


How do Patient Safety Organizations Work?

The following scenario illustrates how a PSO could work for your healthcare organization:

Joe was recently admitted to a long-term care home. Upon admission, staff discovered he had a urinary tract infection. A physician ordered Bactrim to treat the infection, unaware that Joe’s medical record indicates he has a severe allergy to the drug.

Because Joe is one of several intakes that day and admissions paperwork is backed up, staff do not notice the allergy and administer Bactrim. Shortly after, Joe complains he’s having difficulty breathing and is soon unresponsive.

Following the incident, staff immediately report details surrounding the medication error in the PSO. After review, the home immediately identifies a gap in their processes that enabled medication to be administered prior to physicians reviewing a patient’s medical history. The home updated their intake process to require a thorough review of new resident’s medical records before any medication can be prescribed or administered.

In this scenario, the facts of the error are not protected; however, the subsequent investigation and analysis to determine the root cause of the error can be declared Patient Safety Work Product (PSWP) and protected if it is reported to the home’s PSO. Should a lawsuit be filed in this case, the additional notes and analysis are protected under federal law.


Are PSOs Mandatory?

In an effort to improve patient safety, many states are now passing regulations requiring pharmacies to implement a CQI program to detect, identify, and prevent prescription errors. The Pharmapod PSO ensures you’re in compliance.

With Pharmapod’s PSO, our patient safety experts become an extension of your quality team to ensure compliance while mitigating patient harm and risk for your organization.

Learn more about how PSOs can benefit your organization – watch our on-demand webinar, Patient Safety Organizations: What’s In It For You? 

Ready to work with a Patient Safety Organization?

The Pharmapod PSO specializes in improving patient safety and the quality of healthcare delivery in pharmacies and long-term/post-acute care homes.  We aggregate and analyze data and information and provide valuable feedback that enables members to learn in the most efficient manner possible. Book a demo today to learn more.