Ask CHPSO

What is Patient Safety Evaluation System and How Long Should we Retain Patient Safety Work Product?

A patient safety evaluation system (PSES) is the system you use to collect, manage and analyze information (patient safety work product) for reporting to the CHPSO Patient Safety Organization. CHPSO has templates to help you get started. It is important to remember that only those incident reports and other documents, such as Event Analysis or sometimes called RCAs, which are collected with the intention of submitting to CHPSO, will be protected from discovery as patient safety work product.

HIPPA may also apply, in which case the retention period would be the greater of the HIPAA retention policy or the following recommended Patient Safety Work Product (PSWP) retention policy:

Record Type Retention Period
Compliance audits and investigations Six years
Contracts leases and supporting documentation when PSQIA provisions apply Life of agreement/lease/equipment, plus six years (unless contact specified longer retention)
Authorization for release of PSWP Six years
PSWP Policies and Procedures, manuals Six years after expiration
Training records: attendance lists, instructors, dates/times, curricula Six years
Research Records related to PSWP (note that special restrictions apply to research with PSWP – check with CHPSO before proceeding):
Contracts with study sponsors and principal investigators, including related documentation; human subject search records 30 years after completion of the research
Other research reporReets Six years

PSWP itself does not have a mandatory retention period. However, if you destroy PSWP and a court decides that the documents were not, in fact, protected, the court could reach out to CHPSO for the documents.

CHPSO convenes a quarterly, national Legal Counsel Discussion Group intended for healthcare organizations’ legal counsel and risk managers, where discussions like this are held. To join, click here. For any questions or comments, please contact CHPSO, info@chpso.org.

“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.

Commands