Organizations and Relationships

The Agency for Healthcare Research and Quality (AHRQ)

AHRQ is one of 11 agencies within the Federal government’s Department of Health and Human Services (HHS). AHRQ, as the lead Federal agency for patient safety research, has been charged with overseeing the implementation of the Patient Safety Act. PSOs, health care providers, and other interested parties should contact AHRQ at pso@ahrq.hhs.gov with requests for assistance.

The Office for Civil Rights (OCR)

The Office for Civil Rights (OCR) has responsibility for interpreting and enforcing the confidentiality provisions of the Patient Safety Act.

PSO Privacy Protection Center (PSO PPC)

AHRQ created the PSO Privacy Protection Center (PSOPPC) to assist PSOs in rendering the data they submit to the NPSD contextually non-identifiable. The PSO PPC also maintains AHRQ’s Common Formats, which include common definitions and reporting formats to more easily compare data about patient safety events.

Network of Patient Safety Databases

The Patient Safety Act requires AHRQ to administer a Network of Patient Safety Databases (NPSD), which will analyze and report on national, non-identifiable, aggregated patient safety event information.

Program Briefs

  • How PSOs Help Health Care Organizations Improve Patient Safety Culture [pdf, 344 KB]
    Developing a culture of safety is an essential task for health care organizations as they strive to eliminate the factors that contribute to medical errors, patient harm, and unsafe conditions. This brief describes how PSOs can help health care organizations improve their patient safety culture. (April 2016)

  • Patient Safety Organizations: A Summary of 2014 Profiles [pdf, 469 KB]
    The PSO program administered by the Agency for Healthcare Research and Quality allows health care providers to voluntarily report information on patient safety events under legal protection and to use this information to develop patient safety interventions and solutions. This brief looks at the evolution of PSOs based on profile information PSOs voluntarily submitted for 2014. (March 2016)

  • Driving Improvement in Medication Safety: Patient Safety Organization Approaches [pdf, 396 KB]
    Patient Safety Organizations (PSOs) create a secure environment where clinicians and health care organizations can share information, including event reports, in order to reduce patient harm.  Using information from discussions with four PSOs as examples, this brief highlights how PSOs use adverse drug event data reported by member hospitals and other providers to drive improvement in medication-related processes and outcomes.  These PSO activities demonstrate some of the variety of ways that analysis of patient safety medication-related event data can help prevent future errors. (February 2016)

  • Lessons From PSOs on Applying the AHRQ Common Formats for Patient Safety Reporting [pdf, 746 KB]
    The Common Formats contain definitions and reporting formats that are designed to help providers consistently report patient safety events. This Brief is based on conversations with seven PSOs and one consultant. It provides early insights on challenges and solutions to adopting the AHRQ Common Formats.(November 2015)
  • Advancing Patient Safety Through Data-Driven Safety Improvement [pdf, 367 KB]
    Patient safety event and quality data can help your organization improve its health care delivery. Now that PSOs can aggregate event-level data, the stage has been set for breakthroughs in our understanding of how best to improve patient safety. Hospitals and other providers benefit from participating in PSOs because they can: Compare results at the national level, across PSOs, and across a larger group of provider types; discover underlying causes of incidents, near-misses, and unsafe conditions in health care delivery; seek additional expertise for decreasing events and improving quality; and identify patterns of rare events, supported by larger report volumes.(July 2015)
  • Strategies Used by PSOs and Other Organizations To Lead Readmission Reduction [pdf, 900 KB]
    Organizations that lead interhospital collaboratives share a common approach to quality and safety improvement, enabling hospitals to succeed in their improvement initiatives. One area these collaboratives address is preventable hospital readmissions, which are too frequent and add unnecessary cost to our health care system. This brief summarizes the findings from discussions with seven organizations that lead interhospital collaboratives to reduce readmissions.These organizations were interviewed because of their unique position as both Patient Safety Organizations and hospital engagement networks. (April 2015)
  • Patient Safety Organizations: A Summary of 2013 Profiles [pdf, 897 KB]
    The PSO program administered by the Agency for Healthcare Research and Quality allows health care providers to voluntarily report information on patient safety events under legal protection and to use this information to develop patient safety interventions and solutions. This brief looks at the evolution of PSOs based on profile information PSOs voluntarily submitted for 2013. (January 2015)

National Quality Forum

The National Quality Forum, under contract to AHRQ, serves as a neutral forum for obtaining public review and expert opinion regarding each version of the Common Formats.