patient safety organization patient safety organization a patient safety organization (pso) is a group, institution, or association that improves medical care by reducing medical errors. common functions of patient safety organizations are data collection and analysis, reporting, education, funding, and advocacy. a pso differs from a federally designed patient safety organization (pso), which provides health care providers in the u.s. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery (see 42 u.s.c. 299b-21 et seq. and www.pso.ahrq.gov.) in the 1990s, reports in several countries revealed a staggering number of patient injuries and deaths each year due to avoidable errors and deficiencies in health care, among them adverse events and complications arising from poor infection control. in the united states, a 1999 report from the institute of medicine called for a broad national effort to prevent these events, including the establishment of patient safety centers, expanded reporting of adverse events, and development of safety programs in healthcare organizations. although many psos are funded and run by governments, others have sprung from private entities such as industry, professional and consumer groups. functions to achieve their goals, patient safety organizations may collect data on the prevalence and individual details of errors. analyze sources of error by root cause analysis. propose and disseminate methods for error prevention. design and conduct pilot projects to study safety initiatives, including monitoring of results. raise awareness and inform the public, health professionals, providers, purchasers, and employers. conduct fundraising and provide funding for research and safety projects. advocate for regulatory and legislative changes. governmental organizations world alliance for patient safety in response to a 2002 world health assembly resolution, the world health organization (who) launched the world alliance for patient safety in october 2004. the goal was to develop standards for patient safety and assist un member states to improve the safety of health care. the alliance raises awareness and political commitment to improve the safety of care and facilitates the development of patient safety policy and practice in all who member states. each year, the alliance delivers a number of programs covering systemic and technical aspects to improve patient safety around the world. at the fifty-ninth world health assembly in may 2006, the secretariat reported that the alliance held patient safety meetings in five of the six who regions and 40 technical workshops in 18 countries. since the launch of the alliance in october 2004, significant progress was achieved in six areas: the first global patient safety challenge, which for 2005–2006 (addressing health care-associated infection) developed the who guidelines on hand hygiene in health care. a patient involvement group, patients for patient safety, built networks of patients’ organizations from around the world, through regional workshops. a patient safety taxonomy was developed to classify data on patient safety problems. prevalence studies conducted on patient harm in ten developing countries. a who collaborating centre was established to develop and disseminate safety solutions. the who draft guidelines on adverse event reporting and learning systems. patients for patient safety (pfps) patients for patient safety is part of the world alliance for patient safety launched in 2004 by the who. the project emphasizes the central role patients and consumers can play in efforts to improve the quality and safety of healthcare around the world. pfps works with a global network of patients, consumers, caregivers, and consumer organizations to support patient involvement in patient safety programs, both within countries and in the global programs of the world alliance for patient safety. therapeutic goods administration and adverse drug reactions advisory committee the therapeutic goods administration (tga) is a unit of the australian government department of health and ageing. the tga approves and monitors prescription and non-prescription drugs (including herbal products), medical supplies and devices and blood and biological products. risks to users are assessed prior to product introduction, and manufacturers are regularly audited for efficacy, quality and safety. manufacturers are required to report adverse drug effects to the adverse drug reactions advisory committee (adrac) of the tga; reporting by medical professionals and consumers is voluntary. adrac notifies medical professionals and the public through recalls and alerts on its website and publications. in december 2003, the australian and new zealand governments signed an agreement to establish a joint regulatory organization for therapeutic products. the australia new zealand therapeutic products authority (anztpa) will replace the australian therapeutic goods administration (tga) and the new zealand medicines and medical devices safety authority (medsafe), and be accountable to the australian and new zealand governments. implementing legislation is scheduled for introduction into both countries' parliaments in july 2006. on 16 july 2007, the new zealand state services minister annette king announced that "the government is not proceeding at this stage with legislation that would have enabled the establishment of a joint agency with australia to regulate therapeutic products." she further advised that "the government does not have the numbers in parliament to put in place a sensible, acceptable compromise that would satisfy all parties at this time. the australian government has been informed of the situation and agrees that suspending negotiations on the joint authority is a sensible course of action." australian commission on safety and quality in health care the australian commission on safety and quality in health care (the commission) was established by the australian, state and territory governments to lead and coordinate national improvements in safety and quality. the commission replaced the australian council for safety and quality in health care in 2006. the commission engages in collaborative work in patient safety and healthcare quality that benefits from national coordination. this includes the development of the australian charter of healthcare rights and the national safety and quality health service standards, improving areas such as patient identification, medication safety, clinical handover and open disclosure, and reducing healthcare associated infection. the commission has also developed the national safety and quality framework to improve the safety and quality of the australian health system. other key areas of work for the commission include national health service accreditation, recognizing and responding to clinical deterioration, patient centered care, safety and quality in mental health and primary care and the development of national safety and quality indicators as part of the information strategies activity. in its role primarily as a coordination and facilitation body, the commission utilizes evidence and data and the experience, enthusiasm and commitment of consumers, clinicians, managers and other stakeholders to influence the system to make changes for the safety and quality of health care in australia. new zealand health quality & safety commission the new zealand health quality & safety commission was established in november 2010 as a crown entity under the new zealand public health and disability act 2000 to lead and co-ordinate work across the health and disability sector for the purposes of: monitoring and improving the quality and safety of health and disability support services helping providers across the whole sector to improve the quality and safety of services. the commission aims to reduce avoidable deaths and harm, reduce wastage, and make the best use of the health dollar. it works towards the new zealand triple aim for quality improvement: improved quality, safety and experience of care improved health and equity for all populations best value for public health system resources. commission programs include medication safety, infection prevention and control, reportable events, consumer engagement and participation, and mortality review committees. national patient safety agency the national patient safety agency (npsa) is an nhs special health authority created in july 2001 to improve patient safety within the national health service (nhs) by encouraging voluntary reporting of medical errors, conducting analysis and initiating preventative measures. since 2005, the npsa has also been responsible for: safety aspects of hospital design, cleanliness and food; safe research practices through the national research ethics service (nres); and the performance of individual doctors and dentists, through the national clinical assessment service (ncas). the npsa identifies patient safety deficiencies with the input of clinical experts and patients, develops solutions and monitors results of corrections within the nhs. initiatives and alerts include hand hygiene, information for doctors and patients on steps to reduce the risk of error, vaccine safety and disclosure of errors to injured patients. in addition, the national reporting and learning system (nrls) allows nhs employees to provide the npsa with reports anonymously. national institute for health and clinical excellence the national institute for health and clinical excellence is an independent organization that produces guidance on public health, health technologies and clinical practice in england and wales. nice has three centers of excellence. the centre for public health excellence develops public health guidance, with information for patients on the diagnosis and treatment of specific illnesses and conditions. the centre for health technology evaluation recommends medicines and evaluates the safety and efficacy of procedures within the national health service. the centre for clinical practice develops evidence-based clinical guidelines for clinicians on the appropriate treatment of people with specific diseases. nice and the national patient safety agency (npsa) cooperate in risk assessment of new technology, monitoring safety incidents associated with procedures, and providing solutions if adverse outcomes are reported. in addition, nice and npsa share reporting in areas known as "confidential enquiries": maternal or infant deaths, childhood deaths to age 16, deaths in persons with mental illness, and perioperative and unexpected medical deaths. united states on july 29, 2005, the united states congress established guidelines for patient safety organizations under the patient safety quality act of 2005. the focus of the legislation is to provide incentives for clinicians to participate in voluntary initiatives to improve the outcomes of patient care, provide information about the underlying causes of errors in the delivery of health care, and to disseminate this information in order to speed the pace of improvement. composition president clinton's advisory commission on consumer protection and quality in the health care industry completed its work on march 12, 1998. its final report. entitled "quality first: better health care for all americans," recommends the following characteristics of a patient safety organization: be located in an entity that is credible and respected. be located in an entity that does not have public or private regulatory responsibilities (i.e., it should not be a licensing, accrediting, or compliance entity). have the ability to collect and analyze data. have mechanisms for communicating with a variety of healthcare entities, facilities, providers, and plans. be linked with initiatives for conducting interdisciplinary research and demonstrations addressing healthcare quality improvement. agency for healthcare research and quality in 2001, the us congress responded to the iom recommendation to create a national center for patient safety by allocating $50 million annually for patient safety research to the agency for healthcare research and quality (ahrq), the lead federal agency for healthcare safety. the ahrq organizes patient safety activities, provides grants to other organizations, serves as a clearinghouse for safety information, and publishes guidelines for evidence-based or "best practices". by 2006, the national guideline clearinghouse (ngc) contained more than 1,700 disease-specific diagnosis, management and treatment recommendations, developed from current medical literature. the goal of the ngc is to provide health professionals and institutions, health plans and health care purchasers an accessible mechanism for obtaining objective clinical practice guidelines. adoption of guidelines has been slowed by physician and hospital concerns that practice guidelines threaten physician autonomy and authority, fuel malpractice liability, and allow managed care insurers to curtail patient care expenditures. under the secretary of health and human services, the agency for healthcare research and quality coordinates the patient safety task force composed of three other agencies with regulatory and data collection responsibilities: the centers for disease control and prevention (cdc) and its national electronic disease surveillance system, the centers for medicare and medicaid services (cms) and state quality improvement organizations, and the food and drug administration (fda). the ahrq, in partnership with data organizations in 37 states, sponsors the nationwide inpatient sample (nis), a database of the healthcare cost and utilization project (hcup). the hcup is a federal-state-industry partnership providing all discharge data from 994 hospitals—approximately 8 million hospital stays each year. the nationwide inpatient sample is the largest all-payer inpatient care database in the united states from which national estimates of inpatient care can be derived. using safety data from the nis, the ahrq has been able to provide