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Related Links
PSRS Web Site
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Even before the release of the 1999 Institute of Medicine report, "To
Err is Human," the National Aeronautics and Space Administration
(NASA) and the Department of Veterans Affairs (VA) were collaborating
to create a system for patient safety reporting. This system provides
information to improve patient safety and further enhance the quality
of healthcare. The VA, which operates more than 150 medical facilities
across the country, formed an expert advisory panel in 1997 to address
patient safety system design. Two years later, the department established
the National Center for Patient Safety (NCPS) and the groundwork for The
Patient Safety Reporting System (PSRS) was initiated. The VA looked to
NASA, a federal sister agency, to be its 'honest broker' to assist in
the development of a confidential, voluntary and non-punitive reporting
system patterned after the highly successful Aviation Safety Reporting
System (ASRS).
In May 2000, senior officials of the VA and NASA signed an agreement to
create the Patient Safety Reporting System (PSRS). This innovative vision
encourages VA employees to report:
- Events or situations that could have resulted in accident, injury,
or illness but did not, either by chance or through timely intervention
('close-calls')
- Unexpected serious occurrences that involved a death, physical injury,
or psychological injury of a patient or employee
- Lessons learned or safety ideas
PSRS medical safety analysts evaluate every PSRS report. In order to
maintain confidentiality, these analysts remove all personal names, facility
names and locations, and other potentially identifying information before
entering reports into a PSRS research database. This de-identified safety
information, provided by the VA employee, would otherwise likely go unreported
and provides insights into human factors issues in medicine.
Designed to complement the VA's current internal reporting systems, the
PSRS is modeled after NASA's Aviation Safety Reporting System, established
in 1975 under a memorandum of agreement between the Federal Aviation Administration
and NASA. The ASRS, operated by NASA Ames Research Center, collects, analyzes
and responds to voluntarily submitted aviation safety incident reports
in order to decrease the likelihood of aviation accidents. Pilots, air
traffic controllers, flight attendants, mechanics, ground personnel and
others involved in aviation operations can submit reports to the ASRS
when they are involved in, or observe, an incident or situation in which
aviation safety was compromised. This system is known for its strict confidentiality
procedures, identification of aviation hazards, extensive database of
frontline personnel accounts of safety incidents, and distribution of
safety products and information.
After the May 2000 joint agreement was signed, employees from NASA Ames'
Human Factors Research and Technology Division conducted intensive workshops
for VA patient safety managers and officers who operate local patient
safety efforts at VA facilities across the country. Based on feedback
received at the workshops, PSRS developed multimedia educational products
and focused outreach materials. In April 2002, NASA and the VA launched
a national roll-out of the new PSRS.
After the national rollout, reports were received immediately. Presently,
PSRS receives and analyzes data, conducts outreach briefings at VA facilities
nationwide, and produces quarterly safety newsletters. PSRS also identifies
ongoing safety hazards based on PSRS reports and distributes this information
throughout the VA. As this effort continues to evolve, development of
information technology tools will maximize analysis of PSRS reports for
ease of database retrieval and the discovery of patterns. The innovations
used in the development of the Patient Safety Reporting System should
provide a proof-of-concept for confidential healthcare reporting systems
nationwide.
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