What is a PSES, really, and how much detail does it require?
November 2013

Providers have great flexibility in designing a Patient Safety Evaluation System (PSES); the following answer describes a “bare bones” PSES focused on reporting events to CHPSO.

A typical PSES is the event evaluation and review plan in place at your facility. From the moment an event is discovered, what is the process that your team takes to document and review what happened? Who is involved? Which groups have access to this information? How is the information maintained and secured?

Perhaps start by making a work flow chart of the process, from the moment an event is discovered up through submitting the event to your PSO, and then create a detailed description of that work flow chart. Additional details you will need to define include:

  • What is protected as Patient Safety Work Product (PSWP)?
    • Event reports that you plan to submit to CHPSO are protected, as is the event review and evaluation of those events.
    • You may, prior to submitting an event to CHPSO, change your mind and unprotect the event report.
  • What information will you submit to your PSO?
    • Usually, this will be reports of events, near misses and unsafe conditions.
    • You are not required to submit all information to your PSO. HOWEVER,
      • Not submitting a particular event report means that report will not be protected.
      • Submitting only a subset of events (e.g., medication events) means that the PSES and PSWP privilege only apply to that subset. Other events are not protected.
      • The more events submitted the better; not submitting events means events cannot be compiled to discover trends, create lessons learned or even recognize possible manufacture errors.
  • How is information submitted to your PSO?
    • Electronically through your event tracking system
    • Manually online

A PSES does not have to be complicated. The PSES should meet the distinct needs, objectives, and structure of your organization. A PSES is not a one-size-fits-all proposition. The construct of a PSES for a small rural physician office may substantially differ from a PSES designed to support a large academic medical center. The PSES is fluid in that you may alter the system at any time to meet changing needs or organizational structure—just be sure that your policies, procedures, and staff education are kept up-to-date to reflect any changes to the defined PSES.

Just take a deep breath and do your best to document your facility’s process that is already in place. This may already be documented, so you just need to review it for accuracy, add the PSO/PSWP information, and give it the title of “Patient Safety Evaluation System”.

Additional tools and assistance, a policy template, and past webinars can be found by members at (website user account required). CHPSO Staff is happy to briefly review your PSES when it is completed.

“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.