According to the Patient Safety Act, users can access  non-identifiable patient safety data only in accordance with the  confidentiality protections established by the Patient Safety Act. However, few of  the 17 PSOs we randomly selected to interview had entered into contracts  or other business agreements with providers to serve as their PSO, and  only 3 PSOs reported having begun receiving patient safety data or  providing feedback to providers. Some PSOs are still  establishing various aspects of their operations; some are waiting for the  common formats for collecting patient safety data to be finalized by  AHRQ; and some are still engaged in marketing their services and  educating providers about the federal confidentiality protections offered  by the Patient Safety Act. By July 2009, AHRQ had listed 65 PSOs in 26  states and the District of Columbia. AHRQ Is in the Process of Implementing the NPSD and Has Developed Preliminary Plans for Using NPSD Data

AHRQ is in the process of implementing the NPSD and developing its  associated components that are necessary before the NPSD can receive  patient safety data—(1) the common formats PSOs and providers will be  required to use if submitting patient safety data to the NPSD and (2) a  method for making these data non-identifiable. AHRQ officials could not provide a time frame for when they expect  the NPSD to be able to receive patient safety data from other providers. AHRQ also has preliminary plans for how to allow the NPSD to serve as an  interactive resource for providers and PSOs and for how AHRQ will  analyze NPSD data to help meet its reporting requirements under the  Patient Safety Act. If each of these components is completed on schedule, AHRQ  officials expect that the NPSD could begin to receive patient safety data  from hospitals by February 2011. The Patient Safety Act also requires that data submitted to the NPSD be  made non-identifiable by removing information that could be used to  identify individual patients, providers, or facilities. However,  AHRQ has yet to develop plans for more detailed analyses of NPSD data  that could be useful for identifying strategies to reduce medical errors. Appendix I: Examples from Established Patient Safety Reporting Systems

Because the Agency for Healthcare Research and Quality’s (AHRQ) efforts  to list Patient Safety Organizations and implement the Network of Patient  Safety Databases are relatively new but some other patient safety  reporting systems are already established, we identified examples of how  selected established patient safety reporting systems encourage reporting  of patient safety event information by providers and facilitate the  development of improvements in patient safety. After selecting the systems, we conducted  structured interviews with representatives of these systems to identify  examples of ways that these systems encouraged providers to submit  patient safety data for analysis and used the data collected by their  systems to help develop improvements in patient safety.
Why GAO Did This Study

The Institute of Medicine (IOM) estimated in 1999 that preventable medical errors cause as many as 98,000 deaths a year among hospital patients in the United States. Congress passed the Patient Safety and Quality Improvement Act of 2005 (the Patient Safety Act) to encourage health care providers to voluntarily report information on medical errors and other events--patient safety data--for analysis and to facilitate the development of improvements in patient safety using these data. The Patient Safety Act directed GAO to report on the law's effectiveness. This report describes progress by the Department of Health and Human Services, Agency for Healthcare Research and Quality (AHRQ) to implement the Patient Safety Act by (1) creating a list of Patient Safety Organizations (PSO) so that these entities are authorized under the Patient Safety Act to collect patient safety data from health care providers to develop improvements in patient safety, and (2) implementing the network of patient safety databases (NPSD) to collect and aggregate patient safety data. These actions are important to complete before the law's effectiveness can be evaluated. To do its work, GAO interviewed AHRQ officials and their contractors. GAO also conducted structured interviews with officials from a randomly selected sample of PSOs.

What GAO Found

AHRQ has made progress listing 65 PSOs as of July 2009. However, at the time of GAO's review, few of the 17 PSOs randomly selected for interviews had entered into contracts to work with providers or had begun to receive patient safety data. PSO officials told GAO that some PSOs were still establishing aspects of their operations; some were waiting for AHRQ to finalize a standardized way for PSOs to collect data from providers; and some PSOs were still engaged in educating providers about the confidentiality protections offered by the Patient Safety Act. AHRQ is in the process of developing the NPSD and its associated components--(1) the common formats PSOs and providers will be required to use when submitting patient safety data to the NPSD and (2) a method for making patient safety data non-identifiable, or removing all information which could be used to identify a patient, provider, or reporter of patient safety information. If each of these components is completed on schedule, AHRQ officials expect that the NPSD could begin receiving patient safety data from hospitals by February 2011. AHRQ officials could not provide a time frame for when they expect the NPSD to be able to receive patient safety data from other providers. AHRQ also has preliminary plans for how to allow the NPSD to serve as an interactive resource for providers and PSOs and for how AHRQ will analyze NPSD data to help meet certain reporting requirements established by the Patient Safety Act. According to AHRQ officials, plans for more detailed analyses that could be useful for identifying strategies to reduce medical errors will be developed once the NPSD begins to receive data.