Objectives

The AMC PSO objectives are as follows:

• To create a bridge between themes driving malpractice activity and factors seen in real-time data with a particular focus on high severity/high significant events seen in root cause analysis (RCA).
• To convene member organizations in response to real-time events and bring context to patient safety issues by providing a secure venue for discussion.
• To translate learnings gleaned from our convening sessions and data analyses into focused clinical interventions that can improve quality, reduce costs, and decrease liability.
• To reach beyond data reporting and generate actionable responses that can inform the development of best practice recommendations.
• To inform institutional patient safety efforts by pinpointing the areas of highest risk and vulnerability to help guide organizational patient safety initiatives.

History

2009
In 2009, the Patient Safety and Quality Improvement Act (PSQIA) was enacted to create a culture of safety by providing federal privilege and confidentiality protections for information that is assembled and reported to a PSO, or developed by a PSO, for the conduct of patient safety activities.

The act promotes the sharing of best practices and knowledge to continuously improve the quality of patient care. Before the PSQIA, legal protections for quality activities were limited in scope and existed only at the state level.

The PSQIA encourages voluntary reporting. Identification of common, systemic errors can be achieved more effectively through the aggregation of information reported from providers across the health care delivery system.

2010
In 2010, The Risk Management Foundation of the Harvard Medical Institutions Incorporated formed a component entity, the Academic Medical Center Patient Safety Organization (AMC PSO) to function as a national convener of clinicians and health care organizations to collect, aggregate, and analyze data, in a secure environment in an effort to identify and reduce the risks and hazards associated with patient care.

2011
CRICO’s AMC PSO began building its Patient Safety Alerts library. This series of patient safety learnings covered by our members is available to the public as part of CRICO’s ongoing commitment towards improving patient safety across the continuum of care.

2012
The AMC PSO released and implemented Version 1 of the Root Cause Analysis Information Exchange (RCAIE) in September 2012.