Is Our Hospital Required to Document a PSES? —R.P., a hospital in Central California
It’s important to define and document a Patient Safety Evaluation
System (PSES) along with Patient Safety Work Product (PSWP). The
Patient Safety and Quality Improvement Act of 2005 defines a PSES
as “the collection, management, or analysis of information for
reporting to or by a patient safety organization.” PSWP refers to
data, reports, records, memoranda, analyses (such as root cause
analyses), or written oral statements which identify or
constitute the deliberations or analysis of, or identify the fact
of reporting pursuant to, a patient safety evaluation system.” In
order to take advantage of the California Hospital Patient Safety
Organization’s federal privilege and confidentiality protection,
designing a PSES will help protect PSWP.
Most health care organizations do not have to reinvent the wheel
when designing a PSES. In fact, the PSES may be considered
as a product of an organization’s already existing event and/or
incident reporting and review processes. When designing your
PSES, consider the following:
Determine how your organization currently handles incident
reports, what is the process, who is involved (e.g. quality,
patient safety, risk management), and how is the information
Differentiate PSWP from non-PSWP.
Review CHPSO’s sample PSES template. Identify PSWP
that you plan to submit to CHPSO within PSES policies.
Where the information is stored (for example, in an access
restricted electronic reporting system or in a locked cabinet).
Identify who will be involved in the reporting, review,
management, and submission process.
The PSES section of the CHPSO
website contains useful information and tools to get
started. And don’t forget to reach out to the CHPSO team
with any questions or comments!
“Ask CHPSO” is a regular column in CHPSO’s Patient Safety
News and is intended to provide answers to common inquiries. If
you have a question, please contact us at (916) 552-2600 or
firstname.lastname@example.org. All inquirers
will remain anonymous.
“Ask CHPSO” is a regular column in the bimonthly Patient
Safety News and is intended to provide answers to common
inquiries. If you have a question, please contact us at (916)
552-2600 or email@example.com. All inquirers will remain