Patient Safety Organizations: Hospital Participation, Value, and Challenges

WHY WE DID THIS STUDY

Researchers have estimated that over 200,000 people die each year because of medical errors in hospitals. Learning from those and other, nonfatal events to improve patient safety is the goal of AHRQ's voluntary Patient Safety Organization (PSO) program. Hospitals' descriptions of their experiences with the program provide insight into the program's progress toward facilitating national learning from patient safety events. This review is the first to explore the extent to which hospitals participate in the PSO program and their perspectives on its value and challenges.

HOW WE DID THIS STUDY

We surveyed a random sample of 600 general acute-care hospitals, achieving a 79-percent response rate. We asked them questions about their experiences working with federally listed PSOs and their perceived value of the program. We also surveyed all federally listed PSOs, achieving a 90 percent response rate. We asked them questions about their experiences working with hospitals and with AHRQ. Finally, we interviewed AHRQ staff and reviewed data on AHRQ's oversight of the program from 2009 through 2017.

WHAT WE FOUND

Over half of general acute-care hospitals work with a PSO, and nearly all of them find it valuable. Among hospitals that work with a PSO, 80 percent find that the PSO's feedback and analysis on patient safety events have helped prevent future patient safety events. However, the PSO program also faces challenges. Hospitals that do not participate do not perceive the PSO program to be distinct from other patient safety efforts. Nearly all of these hospitals cited redundancy relative to other patient safety efforts as a reason they do not participate. Uncertainty over the program's legal protections and determining what information is protected can be challenging for hospitals. This may discourage them from disclosing data to their respective PSOs or participating at all. Although the Common Formats (standard methods for reporting patient safety data) enable AHRQ to aggregate and analyze data, requiring them for the Network of Patient Safety Databases (NPSD) may slow its progress. Forty-two percent (31 of 74) of PSOs cannot contribute to the NPSD because they do not use the Common Formats. Finally, AHRQ provides technical assistance that PSOs find helpful, but its guidance falls short of meeting PSOs' needs.

WHAT WE RECOMMEND

Our report made three recommendations. AHRQ concurred with our recommendations to develop and execute a communications strategy to increase nonparticipating hospitals' awareness of the PSO program and the program's value to participants and to update guidance for PSOs on processes for listing PSOs. AHRQ partially concurred with our recommendation to take steps to encourage participation in the NPSD, including accepting data into the NPSD in other formats in addition to the Common Formats.