The Patient Safety and Quality Improvement Act Effective Strategies Report to Congress

Project Overview

The Agency for Healthcare Research and Quality (AHRQ) leads federal efforts in patient safety research and oversees the implementation of the Patient Safety and Quality Improvement Act (PSQIA). Congress enacted PSQIA in 1995, largely in response to a 1999 report, To Err Is Human: Building a Safer Health System, by the then-named Institute of Medicine. The report raised awareness of “the nation’s epidemic of medical errors” and recommended a comprehensive strategy for making healthcare safer. PSQIA authorized AHRQ to implement a Network of Patient Safety Databases (NPSD) and establish a system of patient safety organizations (PSOs) charged with collecting and analyzing confidential patient safety data.

The confidentiality protections extended to providers under this law seek to encourage reporting of events that adversely affect patients and enable PSOs and providers to collaborate in the development and implementation of patient safety improvement strategies. Providers may also authorize a PSO to release nonidentifiable information to the NPSD, with the Privacy Protection Center further stripping it of all identifying information. The larger amount of data facilitates identification of patterns and trends.

Insight is developing this Report to Congress to fulfill the statutory requirements outlined in the PSQIA, which calls for a report on effective strategies for reducing medical errors and increasing patient safety.

As part of this project, Insight—

  • Reviews, analyzes, synthesizes, and summarizes all available information from previous AHRQ reports, PSO information, NPSD reports, and other salient reports identified by AHRQ
  • Drafts a report to AHRQ and Congress on effective strategies for improving patient safety
  • Coordinates, synthesizes, and responds to public comments, AHRQ, and National Academy of Medicine Review
  • Drafts and disseminates products such as white papers, announcements, and presentations on findings


Report to Congress