Mistakes

Last month federal officials issued final regulations for implementing the Patient Safety and Quality Improvement Act of 2005. Going into effect on Jan. 19, 2009, the final rule:

* Allows physicians, hospitals and others in the health care system confidentially and voluntarily to report medical errors and other safety issues to patient safety organizations. The PSOs will analyze the data and identify trends that can inform patient safety improvement efforts.

* Keeps confidential any patient safety quality improvement reviews, deliberations and analyses reported to PSOs. Medical records, billing or discharge data, and any other patient or health professional information that exists outside of a patient safety evaluation system are not confidential or privileged.

* Prohibits health plans, regulatory agencies, licensing boards and government organizations that operate mandatory reporting systems from becoming PSOs. Such entities may serve as PSO parent organizations.

* Allows PSOs with parent organizations to share certain staff and computer network resources if they meet security, workload, ethics and other requirements.

* Requires PSOs to be engaged primarily in efforts to improve patient safety.

The airline industry is best at it. They set the curve for the reporting and analysis of accidents and errors. The medical world is cloaked in errors of the past never reported, fear, litigation, ego, and pride. But the pooling of information about error, and the analysis of confidential pools of such information is vital to finding the "cause" of error, and eliminating it. It's that simple.

All recent legislative efforts and discussion hinge on a voluntary, confidential, privileged reporting of safety information to groups called patient safety organizations (PSO). These PSOs are certified by the Agency for Healthcare Research and Quality, part of the Dept. of Health and Human Services and will serve as analysts for the data.  Information about error cannot come from legal discovery, and does not apply to medical records, billing or other records normally kept outside safety reporting systems.

Unfortunately, the need for voluntary participation will be an obstacle for PSOs trying to gather comprehensive data on medical errors and patient safety. Physicians and others involved in the management of healthcare aren't thrilled about reporting themselves, and are wary of "anonymous" labels. Is it really anonymous reporting?

AHRQ has certified 20 PSOs around the country.  Much like the National Transportation Safety Board does for the flight industry, the PSO plans to offer accident and event investigation, and that can't be a bad thing if it will stop one wrong leg from being amputated, or one death from accidental medication error.