Education and Practice Patient Safety Organizations – 2017 Update
John M. Kessler
Community pharmacy is doing much better in its patient safety efforts these days as evidenced by the new deployment of patient safety evaluation systems in large numbers of pharmacies. Since 2008, more than 8,000 community pharmacies have voluntarily implemented systems to identify risks, report errors and near-misses, learn from these events and implement corrective actions to reduce the burden of harm1. In addition, these pharmacies are sharing their event data within Patient Safety Organizations (PSOs) to help one another learn. This sharing has not always been the case. Community pharmacy does not have a long history of systematically learning from mistakes nor effectively identifying and reducing risks. This contrast begs the question: why have so many community pharmacies improved their safety efforts? The pivotal Institute of Medicine report in 20002 identified that errors and adverse events were largely unreported due to a national culture of fear, blame, and litigation. The IOM report concluded that errors and harm will repeat unless they are reported, investigated, analyzed, shared with others, and acted upon. A major recommendation was that: Congress should pass legislation to extend peer review protections to data related to patient safety and quality improvement that 28
are collected and analyzed by health care organizations for internal use or shared with others solely for purposes of improving safety and quality. This recommendation set the stage for the federal Patient Safety and Quality Improvement Act (the “Act”) of 2005 and the formation of Patient Safety Organizations (PSOs), whose role is to provide a confidential and protected framework for reporting, analyzing, and sharing reports of errors, adverse events, close-calls, unsafe conditions, root cause analyses, and other quality improvement-related information. Detailed information about PSOs can be found here: https://www.pso.ahrq.gov/ For the first time ever, pharmacies that are not part of hospital systems or other peer review programs can now benefit from statutory protections, but only if they voluntarily joined a PSO. As of March 29, 2017 there are 86 PSOs in existence (https:// www.pso.ahrq.gov/listed/). Eight PSOs self-identify pharmacy as a specialty, and three list retail pharmacy as the type of facility served. Table 1 lists the PSOs located in North Carolina; two serve the Carolinas HealthCare System, and one serves primarily hospitals and related facilities. Table 2 shows those PSOs that specifically list retail pharmacy as the type of facility served. Pharmacies can join one or more PSOs regardless of where the PSO is located.
Table 1. PSOs Located in North Carolina* Carolinas HealthCare System Patient Safety Organization Carolinas Rehabilitation Patient Safety Organization NC Quality Center PSO (NC Hospital Association) Table 2. PSOs Listing Retail Pharmacy as the Type of Facility Served* Alliance for Patient Medication Safety (serves all states) The PSO Advisory, LLC (serves all states) The Patient Safety Research Foundation, Inc. (serves Walgreens Pharmacy) *For up-to-date contact information to all PSOs see: https:// www.pso.ahrq.gov/listed. Tables 1 and 2 are based on voluntarily reported profiles from each PSO. What is the PSO mission? PSO mission statements vary, yet they share two common themes – 1) to achieve the highest levels of quality and safety, and 2) to protect patient safety work product from discovery.
