PSO Background


Patient Safety Organizations*
In 1999, the Institute of Medicine (IOM) issued a landmark report entitled, "To Err is Human: Building a Safer Health System," which highlighted critical areas of research and activities needed to improve the safety and quality of health care delivery. One critical area of the IOM report addressed the reporting and analysis of data on adverse events.

The IOM report and its findings spotlighted a serious need to capture data that would help to reduce harm to patients. Addressing this need, Congress passed The Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act). The Patient Safety Act authorizes the creation of Patient Safety Organizations (PSOs) to improve safety and quality through the collection and analysis of data on patient events.

PSOs are organizations that share the goal of improving the safety and quality of health care delivery. Organizations that are eligible to become PSOs include: public or private entities, profit or not-for-profit entities, provider entities such as hospital chains, and other entities that establish special components to serve as PSOs.
By providing both privilege and confidentiality, PSOs create a secure environment where clinicians and health care organizations can collect, aggregate, and analyze data that enable the identification and reduction of risks and hazards associated with patient care.


Clinicians and other people interested in patient safety may wonder what led to the creation of Patient Safety Organizations (PSOs). To answer this question, it is helpful to look to the past.

In the past, individual facilities and states have encouraged clinicians to report patient safety events. However, two major impediments have stood in the way of collecting enough representative data to make significant improvement:

Fear of disclosure
: Physicians and other clinicians traditionally have been reluctant to participate in peer review of patient safety events for fear of legal liability, professional sanctions, or injury to their reputations.

Isolated data
: Patient safety event reports traditionally have not been standardized to allow aggregation of data and sharing across different institutions. An insufficient number of reports have made it difficult to identify and mitigate underlying patterns of causal factors.

*From the Agency for Healthcare Research and Quality