Ask CHPSO

Is Our Hospital Required to Document a PSES?
—R.P., a hospital in Central California

Dear R.P.,

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:

  1. 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 documented.
  2. Differentiate PSWP from non-PSWP.
  3. Review CHPSO’s sample PSES template. Identify PSWP that you plan to submit to CHPSO within PSES policies.
  4. Where the information is stored (for example, in an access restricted electronic reporting system or in a locked cabinet).
  5. 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 info@chpso.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 info@chpso.org. All inquirers will remain anonymous.

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