Safety and Quality Event Reporting
Safety and Quality Event Reporting: The Patient Safety and Quailty Improvement Act of 2005
In 2005, the AMA led the passage of the Patient Safety and Quality Improvement Act (Public Law 109-41 109th Congress).
Patient Safety Bill text and summary: S.544 bill text as passed by the Senate on July 21, 2005, summary of S.544 provisions.
On Nov. 21, 2008, HHS issued the final rule that establishes the authorities, processes, and requirements for implementing the Patient Safety Act. The final rule captures the intent of the law; to create a voluntary reporting program through which health care providers can share information relating to patient safety events with patient safety organizations (PSOs) on a privileged and confidential basis in order to improve patient safety and the quality of care.
The Agency for Healthcare Research and Quality (AHRQ) has implemented and is overseeing the process for certification and listing of PSOs. The Office of Civil Rights (OCR) is responsible for investigating and enforcing compliance with the confidentiality requirements.
The AMA continues to work with AHRQ in order to maximize physician participation in patient safety event reporting. The AMA efforts focus on physician outreach and informing physicians of the protections in the Patient Safety Act, Patient Safety Evaluation Systems (PSES), and Patient Safety Organizations (PSOs) that the Patient Safety Act creates. Through education initiatives and materials, the AMA aims to help physicians become familiar with the reporting process, comfortable with the protections offered in the Patient Safety Act, and aware of opportunities to participate in or provide leadership to their organizations’ PSO reporting system.
The AMA also provides ongoing feedback to AHRQ on Common Formats, which would facilitate the voluntary collection of patient safety and quality event data and reporting event information to PSOs. AMA comments to AHRQ on Common Formats Version 1.0, Oct. 14, 2009
Patient Safety Collaborative with AHRQ
In 2010, the AMA launched a Patient Safety Learning Collaborative (PSLC), in support of the Patient Safety Organization Privacy Protection Center requirements to engage the PSO and physician communities to improve data collection on patient safety events. The collaborative brought together physician and Patient Safety Organization leaders to raise awareness about PSOs and assist physicians in enhancing the patient safety strategies they employ across the continuum of care. The PSLC meetings included primarily the leaders of state medical societies and AHRQ-certified PSOs. The AMA used the Agency for Healthcare Research and Quality Common Formats as roadmaps, or guides, to drive physician participation in the collaborative and related patient safety activities.Patient Safety Act Tools and Resources
To help physicians optimize the quality and safety of patient care, the AMA developed the "Physician's Guide to Patient Safety Organizations". The guide to patient safety organizations (PSOs) assists physicians in voluntary reporting of adverse safety events, and is full of practical information, including a glossary, a reporting checklist and a work-flow model. It also includes an analysis of patient safety evaluation systems and the Patient Safety and Quality Improvement Act of 2005, which created PSOs.