Reporting Patient Safety Events Challenge

Patient Safety Organizations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ) create a safe environment for health care providers to collect, aggregate, and analyze data without fear of legal discovery. This flow of information is designed to improve the quantity and quality of actionable information available and ultimately improves the safety of health care by identifying and reducing the risks associated with patient care. 

The Institute of Medicine, in its 2011 report on Health IT and Patient Safety:  Building Safer Systems for Better Care, recommended voluntary adverse event reporting by health care providers and promoted PSOs using AHRQ’s Common Formats as the “best option” for advancing effective reporting. Because medical errors occur in a complex environment and are caused by multiple factors, adverse event reporting must capture a wide range of data, which may go beyond structured data required by Common Formats. Furthermore, providers may need to send the same or similar data to more than one PSO as well as to other public health or health oversight agencies.