How do we decide what to put in our patient safety evaluation system (PSES)?
—S.G., a hospital in southern California

A patient safety evaluation system is the system you use to collect, manage, and analyze information (patient safety work product) for reporting to your patient safety organization, CHPSO. There is no one-size-fits-all policy; each health care facility has needs that others may not experience. It is important to keep in mind that the PSES can be an evolutionary document and it is beneficial to revisit it regularly. While most hospitals submit all incident reports and RCAs to CHPSO, some may only report specific event categories. The policy may include a disclaimer of items that are an exception, such as documents that are to be used in criminal, civil, or disciplinary proceedings, which are not considered PSWP. CHPSO has a few templates and a toolkit to help you get started. It is important to remember that only those incident reports and other documents, such as RCAs, that are collected with the intention of submitting to CHPSO will be protected from discovery as patient safety work product.

“Ask CHPSO” is a regular column in the bimonthly Patient Safety News and is intended to provide answers to common inquiries. If you have a question, please contact us at (916) 552-2600 or All inquirers will remain anonymous.