Patient Safety Quality Improvement Act
Kazia Berman
"To Err is Human" (1999)
To Err is Human
- Prior:
- The Public Health Service Act (1944)
- "To Err is Human", Insitute of Medicine Report:
- Approximately 100,000 people die per year from preventable medical errors
- This report helped spark the desire for further research into patient safety, which led to the PSQIA
What is the PSQIA?
What is the PSQIA?
- Signed into law by former President Bush in 2005
- Implemented by the Department of Health and Human Services, the Agency of Healthcare Research and Quality, and the Office of Civil Rights
- Goals:
- Encourage reporting on unsafe conditions
- To reduce medical errors by establishing Patient Safety Organizations (PSOs)
Patient Safety Organizations
PSOs and PSWPs
- External organizations that work with hospitals to analyze Patient Safety Work Products (PSWPs) and study medical errors
- Not federally funded
- The list of PSOs is regulated by the Agency for Healthcare Research and Quality (AHRQ)
What is Patient Safety Work Product (PSWP)?
PSWPs
- Patient Safety Work Product (PSWP):
- Data, records, and information provided to, reported to, or developed by Patient Safety Organizations
- Does not include a patient's billing, discharge, or personal information
- Using PSWPs to conduct research about safety issues rather than patient information protects hospitals from litigation
- Unless a hospital releases information that does not fit PSWP guidelines
My Thoughts:
My Thoughts
- Hospital's bottom line vs. patient's lives
- Medical ethics:
- nonmaleficence and beneficence
- Lack of accountability
- No incentives for reporting
- Act does not encourage medical staff trainings or hospital reforms
- Medical errors may be a systemic problem