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
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
You are not required to submit all information to your
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
How is information submitted to your PSO?
Electronically through your event tracking system
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
“Ask CHPSO” is a regular column in the bimonthly Patient
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