TABLE C–1c Federal Patient Safety/Health Care Reporting and Surveillance Systems

Federal Agency



Name of System

National Center for Patient Safety Reporting Systema

Patient Safety Reporting Systemb

Type of system



History of reporting/ surveillance system

In 1997, the VA implemented the Patient Safety Improvement (PSI) initiative after identifying patient safety as a high priority within its health care system. The PSI included a Sentinel Event Reporting System, whose purpose was to prevent adverse events through an understanding of systems-level causes and then following up with corrective actions. This system was in place until late 1998 when, based on the recommendations of the External Panel on Patient Safety System Design, the VA established the dedicated National Center for Patient Safety to redesign the PSI in order to increase reporting and enhance the utility of reports. Then, after conducting two pilot studies, full-scale national rollout of the reporting system took place between April and August 2000.

In May 2000, the VHA formalized an agreement with NASA to develop PSRS, which is designed to be a complementary external system to the internal NCPS Reporting System. For the VA, the NCPS is a “safety valve” for incidents that otherwise may go unreported to the internal NCPS system. Pilot testing of PSRS began in March 2001 at a few selected VA medical centers, and the system became available to all VA medical centers in FY 2002. The VA pays NASA to independently operate PSRS according to the Memorandum of Understanding between the two agencies. PSRS builds on more than 25 years of NASA experience in running the Aviation Safety Reporting System for the Federal Aviation Administration.

aInformation on the NCPS Reporting System has been obtained from the following sources: Agency for Healthcare Research and Quality (2002); Overhage (2003), U.S. Code (1980), Department of Veterans Affairs (2001, 2002).

bInformation on the PSRS has been obtained from the following sources: Agency for Healthcare Research and Quality (2002), U.S. Code (1980), Department of Veterans Affairs (2001), Department of Veterans Affairs and National Aeronautics and Space Administration (2000).

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