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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

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