Establish a Patient Safety Evaluation System (PSES)


What is a PSES?

  • A PSES defines the processes within an organization for the collection, management, analysis and reporting of patient safety work product (PSWP) to a PSO.
  • For data to qualify as PSWP, it must be developed within a PSES.
  • It also includes supporting documents explaining how information enters the PSES, who has access to the system, and the physical space or equipment used by the PSES.

What is Patient Safety Work Product (PSWP)?

Clear identification of what information is considered PSWP and when this information becomes PSWP is an essential step in creating an environment to maintain the privilege and confidentiality requirements when working with a PSO. Information becomes PSWP when the provider develops or assembles the information as part of a PSES, and the information is either reported to a PSO or identifies or constitutes the deliberations or analysis of the PSES.

  • Information related to patient safety or quality;
  • PSWP can take the form of data, reports, records, memoranda, analyses (such as root cause analyses), or written or oral statements for the conduct of patient safety activities;
  • PSWP is documents that reflect the deliberations and analysis surrounding patient safety and quality improvement activities that are performed within your PSES;
  • PSWP is protected when collected for the purpose of reporting to a PSO and is reported to a PSO; and
  • PSWP does not include a patient’s medical record, billing and discharge information, or any other original patient or provider information.

Templates/Tools to Develop a PSES

Resources to help you design and develop a PSES for your organization.


PSES Three-Part Template (North Carolina Template):