Patient Safety Organization

The Empire State Patient Safety Assurance Network (ESPSAN) has been in existence since 2010.

On this page:

About the PSO

The Patient Safety Organization (PSO) component of the University at Buffalo was established and received federal certification from the Agency for Healthcare Research and Quality (AHRQ) in January 2010 to March 2017. ESPSAN voluntarily delisted and still operates as a Patient Safety Network.

Our objective is to conduct meaningful quality improvement collaborations with health care sites in Upstate New York utilizing health information technology to improve quality of care, reduce adverse drug events, and enhance patient safety.

Mission

Our mission is to conduct meaningful quality improvement collaborations with health care sites in Upstate New York utilizing health information technology to improve quality of care, reduce adverse drug events, and enhance patient safety.

What is a PSO?

Patient Safety Organization (PSOs) are external entities that collect and analyze patient safety-related information for the purposes of identifying underlying causes of adverse events in healthcare. PSOs were created by the Patient Safety and Quality Improvement Act of 2005 in response to the number of preventable medical errors that were occurring in the United States healthcare system. This Act enables the confidential reporting of patient safety events. Data is collected and analyzed in standardized manner (common definitions and reporting formats, known as Common Formats) to provide uniformity in reporting of patient safety events improve health care providers’ efforts to eliminate harm.

Patient safety events that are reported include:

  • Incidents: patient safety events that reached the patient, whether or not there was harm involved
  • Near misses (or close calls): patient safety events that did not reach the patient.
  • Unsafe conditions: circumstances that increase the probability of a patient safety event occurring.

Elements of a PSO

The Patient Safety and Quality Improvement Act of 2005 provides legal protection of health information to enhance the data available to assess and resolve patient safety and health care quality issues. Three key elements of the Patient Safety Act include:

  • Patient Safety Organizations (PSO): A private or public entity or component thereof listed by the Secretary of the HHS whose purpose is the collection and analysis of Patient Safety Work Products (PSWPs) in efforts to improve patient safety and the quality of health care delivery.
  • Patient Safety Evaluation Systems (PSES): The collection, management, or analysis of information for reporting to or by a patient safety organization.
  • Patient Safety Work Product (PSWP): Any data, reports, records, memoranda, analysis (such as Root Cause Analysis) or written or oral statements which are assembled or developed by a provider for reporting to a patient safety organization and are reported to a PSO or are developed by a PSO and which could result in improved patient safety, health care quality, or health care outcomes of which identify or constitute the deliberations of analysis of a patient safety evaluation system.

Patient Safety Work Products are both privileged and confidential by The Act:

  • Privileged: Protected from Federal, State, and local courts or administrative bodies, even if subpoenaed, with limited exceptions.
  • Confidential: Providers may not disclose the PSWP outside of permissible disclosures, and are subject to penalty by doing so.

Patient Safety Activities

  • Efforts to improve patient safety and the quality of health care delivery.
  • The collection and analysis of patient safety work product.
  • The development and dissemination of information with respect to improving patient safety, such as recommendations, protocols, or information regarding best practices.
  • The utilization of patient safety work product for the purposes of encouraging a culture of safety and of providing feedback and assistance to effectively minimize patient risk.
  • The maintenance of procedures to preserve confidentiality with respect to patient safety work product.
  • The provision of appropriate security measures with respect to patient safety work product.
  • The utilization of qualified staff.
  • Activities related to the operation of a patient safety evaluation system and to the provision of feedback to participants in a patient safety evaluation system.

Internal Organization

  • Patient Safety Organization Program Director: Gene D. Morse, PharmD, FCCP, BCPS
  • Patient Safety Officer: Jeffrey C. Lombardo, PharmD, BCOP
  • Patient Safety Organization Program Administrator: Kelly Patton, MSHA

More information on our staff can be found here.