Download the 2018 Annual PSO Report

The Center for Patient Safety (CPS) is certified as a federally-designated Patient Safety Organization (PSO) in compliance with the provisions of the federal Patient Safety and Quality Improvement Act of 2005 (PSQIA).

The rule supporting PSOs has now been around for 10 years with popularity continuing to increase. Of the more than 80 PSOs in the country currently, each is slightly different and has different services, but their goals are the same:

  1. identify what medical errors are occurring,
  2. determine why they are occurring, and
  3. share the learnings with others to prevent them from occurring again.
2018 Annual PSO Report
Download PSO Report

PSOs can do this in an aggregate way because of the federal designation they are granted under the Agency for Healthcare Research and Quality (AHRQ). Strict criteria are used to identify eligible organizations to provide support for the analysis and learning that comes from reviewing unexpected errors that occur during the delivery of healthcare services.

CPS provides PSO services across the continuum of health care and is positioned to assist new and current participants in gaining valuable learning and obtaining the federal protections that are available within the PSQIA – but most importantly, to reduce preventable harm. CPS works with health systems, emergency medical services (EMS), long term care, ambulatory surgery centers (ASC) and home-based care. CPS has two data collection platforms, one of which collects events using common data formats from health systems including long term care, home-based care, medical offices, and hospital. The second data collection platform uses a common data set from EMS, both ground and air.

CPS was one of the first federally designated PSOs in 2008. Today, we are one of the largest, most active and diverse PSOs in the country.

The data contained in this report is from the CPS’ PSO database. Licensed healthcare providers may participate in a PSO in order to share information, learn from the sharing, gain federal protection and ultimately reduce mistakes and patient harm. PSO participation is voluntary and organizations may choose to submit only the more adverse events to share lessons learned. The event types and their severities, along with the additional information contained in this report, are de-identified as required by the PSQIA.

The goal of this report is to present an overview of the findings within all of the events reported to the CPS PSO, to learn how and why events are occurring, and inform providers and others about how to prevent future occurrences.

This report will highlight some of the predominant events that were reported within the dates of January 1, 2018 through December 31, 2018.