Why OIG Did This Review. Researchers have estimated that over 200,000 people die each year because of medical errors in hospitals. Learning from those and other, nonfatal events to improve patient safety is the goal of the PSO program. Hospitals' descriptions of their experiences with the program provide insight into the program's progress toward facilitating national learning from patient safety events. This review is the first to explore the extent to which hospitals participate in the PSO program and their perspectives on its values and challenges. It builds on previous Office of Inspector General work from 2010 that found 27 percent of hospitalized Medicare beneficiaries experienced harm because of medical care. OIG recommended, among other things, that AHRQ encourage hospitals to participate in the PSO program. How OIG Did This Review. We selected a random sample of 600 general acute-care hospitals to survey and achieved a 79-percent response rate. We asked them detailed questions about their experiences in working with federally listed PSOs and their perceived value of the program. We also surveyed all federally listed PSOs, achieving a 90-percent response rate. We asked them detailed questions about their experiences in working with hospitals and with AHRQ. Finally, we interviewed AHRQ staff and reviewed data on AHRQ's oversight of the program from 2009 through 2017. What OIG Found. Over half of general acute-care hospitals work with a PSO, and nearly all of them find it valuable. Among hospitals that work with a PSO, 80 percent find that the PSO's feedback and analysis on patient safety events have helped prevent future patient safety events. However, the PSO program faces challenges. Hospitals that do not participate do not perceive the PSO program to be distinct from other patient safety efforts. Nearly all of these hospitals cited redundancy relative to other patient safety efforts as a reason they do not participate. Uncertainty over the program's legal protections and determining what information is protected can be challenging for hospitals. This may discourage them from disclosing data to their respective PSOs or participating at all. Although the Common Formats (standard methods for reporting patient safety data) enable AHRQ to aggregate and analyze data, requiring them for the NPSD may slow its progress. Forty-two percent (31 of 74) of PSOs cannot contribute to the NPSD because they do not use the Common Formats. Challenges with the Common Formats reflect the limits of using a standardized approach to capturing patient safety data. Finally, AHRQ provides technical assistance that PSOs find helpful, but its guidance falls short of meeting PSOs' needs. What OIG Recommends. AHRQ should do more to support and promote the PSO program. Specifically, the Office of Inspector General recommends that AHRQ (1) develop and execute a communications strategy to increase nonparticipating hospitals' awareness of the PSO program and the program's value to participants; (2) take steps to encourage PSOs to participate in the NPSD, including accepting data into the NPSD in other formats in addition to the Common Formats; and (3) update guidance for PSOs on processes for listing PSOs. AHRQ concurred with our first and third recommendations and partially concurred with our second recommendation.
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