Patient Safety Events (PSEs) are defined as adverse events that occur during healthcare delivery. They include errors or near misses that put patients at risk. PSEs have become a major focus of patient safety initiatives around the globe.
The Joint Commission has published a new standard called JCAHO PS-1. This requires hospitals to report all PSEs within 24 hours.
This is a huge step forward in improving patient safety. Hospitals now have a way to identify and address issues before they happen. When it comes to patient safety event reporting, the U.S. healthcare system is a laggard compared with other industrialized nations.
In 2013, only 5% of hospitals in England and Wales reported at least one adverse event that led to harm or death, according to data from the National Patient Safety Agency. In Canada, there were about 40 such events per 100,000 admissions.
But as the United States looks for ways to improve its performance on this front, some experts say it may be time to look beyond traditional methods like surveys and mandatory reporting. They say we need new approaches to help identify problems before they happen and prevent them from becoming serious issues.
“We have been looking for solutions to these kinds of problems for decades, but we haven’t really found anything that works very well,” said Dr. Robert Wachter, a professor of health policy and management at Stanford University’s School of Medicine.
Dr. Wachter says the most common approach to identifying problems is through voluntary reporting systems. These systems allow organizations to share information about incidents that don’t necessarily lead to harm. However, he says, they are limited by what people feel comfortable disclosing. And even if everyone discloses everything, it will still take months or years to analyze the reports.
