Patient Safety Organization, Protecting Patients from Medical Error

The 1999 Institute of Medicine report concluded that from 44,000 to 98,000 people die annually due to errors in inpatient hospital treatment. The information has created quite a stir in the health care industry for the last ten years.

How would the EMS world stack up with regard to medical errors? No one knows.

In January, 2009, regulations created for the first-ever national system for medical providers to voluntarily report errors, near misses and other patient safety events to designated organizations – Patient Safety Organization, PSOs – while having some assurance that the information will be protected from legal discovery and kept confidential – something Missouri EMS agencies or professionals have never had in the current Peer Review process, hence no current method for medical error analysis. When an ambulance service has a quality improvement review of a call that goes bad, the crewmembers are interviewed, medical directors talk to them, records are made – but lawyers can get to those records.

Industry representatives have gone to the state legislature a total of six times since 1997, to have the law changed, but have never gained the ability to have protected peer review documents.

“How do you come up with procedures and a work culture to report medical mistakes and study them if there is no protection of the information?” asks Jason White of, Director of Compliance with MAST Ambulance in Kansas City, Missouri.

“For hospitals, such records are not open to lawyers and this definitely encourages improvement. EMS has struggled to have the same ability.”
White cites several examples of improvement over the years such as a hospital universal DNR wrist band with one color to identify it. Prior to this change several years ago, staff members transitioning from other facilities would mistake a DNR wrist band for something else, or vice versa, because facilities used their own differing bands.

“The EMS industry now universally uses retractable needles,” says White. “The result is the near complete elimination of dirty needle sticks after starting IVs. So how can we identify other similar issues to make EMS safer for patients and staff?”

The new federal law implements the Patient Safety and Quality Improvement Act of 2005 (PSQIA), signed into law by President Bush in July 2005.

The concept is to allow providers to seek expert help in understanding these patient safety events and prevent their recurrence. The system’s framework was developed by the Department of Health and Human Services (HHS).

According to the ECRI Institute, a PSO is a public or private organization with expertise to analyze the risks and hazards in patient care and to make recommendations to improve healthcare quality and patient safety. The intent is to gather data from doctors, hospitals and medical clinics to find medical mistakes, seek commonalities and solutions.

The Missouri PSO is a nonprofit entity called the Missouri Center for Patient Safety. Certified by the federal government in November of 2008 as the seventh center in the nation, the PSO is comprised of the Missouri Hospital Association, the Missouri Medical Society and Primerus, a private company which provides quality assurance processes for the federal Medicare program.

HHS estimates as many as 50 to 100 organizations across the nation will be certified as PSOs within three years.

The law certifies and allows PSOs to receive and analyze patient safety work product (which includes information about adverse events, near misses, and quality-related data), as well as provide feedback to providers about the events—all in a protected legal environment. The hope is that by analyzing a large volume of information, PSOs will detect patterns and common themes to explain the underlying causes of medical errors.

Most recently, Missouri EMS industry representatives approached the Missouri Center for Patient Safety in order to determine whether EMS might fit under their umbrella. They found that it does. The Missouri PSO was very excited to work with EMS and has approached the Health Care Foundation in St. Louis on their behalf for a three-year grant to cover expenses. The grant was submitted in August.

The new relationship will offer EMS several benefits such as low or no cost excellent peer review protection, serious study of data which can be gathered professionally to confront and resolve errors and, from a long term perspective, a great possibility of being able to match EMS data with hospital data in order to evaluate outcomes for patients – something that has never happened before.

The hope is to see positive change in the EMS work culture so that issues can be studied today in order commit to action over the course of the next five to ten years.

“From a peer review perspective, it’s a great fit for Missouri EMS to be working directly with the Missouri Center for Patient Safey,” says White. “I believe it will save many lives.”

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