Patient Safety Organizations: Key Insights, Challenges, and Opportunities

Despite nationwide efforts to improve patient safety, patient harm events in hospitals remain a serious concern. The Patient Safety Organization (PSO) program, authorized by the Patient Safety and Quality Improvement Act of 2005, is the flagship Federal program to facilitate patient harm reporting and learning on a national scale. However, in the years since the PSO program was created, OIG work has found consistently high patient harm rates in hospitals and a lack of hospital identification of these events, which are areas that the PSO program was designed to address. OIG work has also found that, although many hospitals find value in PSOs, hospitals find it challenging to navigate the legal protections that surround their work with PSOs. This study will build on previous OIG work by determining the extent to which hospitals participate in the PSO program nationwide and identifying the program's successes and challenges. We will also identify opportunities for the PSO program to mitigate these challenges and leverage new strategies to improve patient safety.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
March 2024	Agency for Healthcare Research and Quality	Patient Safety Organizations: Key Insights, Challenges, and Opportunities	Office of Evaluation and Inspections	OEI-01-24-00150	2025