Even before the release of the 1999 Institute of Medicine report, "To Err is Human," the National Aeronautics and Space Administration (NASA) and the Department of Veterans Affairs (VA) were collaborating to create a system for patient safety reporting. This system provides information to improve patient safety and further enhance the quality of healthcare. The VA, which operates more than 150 medical facilities across the country, formed an expert advisory panel in 1997 to address patient safety system design. Two years later, the department established the National Center for Patient Safety (NCPS) and the groundwork for The Patient Safety Reporting System (PSRS) was initiated. The VA looked to NASA, a federal sister agency, to be its 'honest broker' to assist in the development of a confidential, voluntary and non-punitive reporting system patterned after the highly successful Aviation Safety Reporting System (ASRS).

In May 2000, senior officials of the VA and NASA signed an agreement to create the Patient Safety Reporting System (PSRS). This innovative vision encourages VA employees to report:

• Events or situations that could have resulted in accident, injury, or illness but did not, either by chance or through timely intervention ('close-calls')
• Unexpected serious occurrences that involved a death, physical injury, or psychological injury of a patient or employee
• Lessons learned or safety ideas

PSRS medical safety analysts evaluate every PSRS report. In order to maintain confidentiality, these analysts remove all personal names, facility names and locations, and other potentially identifying information before entering reports into a PSRS research database. This de-identified safety information, provided by the VA employee, would otherwise likely go unreported and provides insights into human factors issues in medicine.

Designed to complement the VA's current internal reporting systems, the PSRS is modeled after NASA's Aviation Safety Reporting System, established in 1975 under a memorandum of agreement between the Federal Aviation Administration and NASA. The ASRS, operated by NASA Ames Research Center, collects, analyzes and responds to voluntarily submitted aviation safety incident reports in order to decrease the likelihood of aviation accidents. Pilots, air traffic controllers, flight attendants, mechanics, ground personnel and others involved in aviation operations can submit reports to the ASRS when they are involved in, or observe, an incident or situation in which aviation safety was compromised. This system is known for its strict confidentiality procedures, identification of aviation hazards, extensive database of frontline personnel accounts of safety incidents, and distribution of safety products and information.

After the May 2000 joint agreement was signed, employees from NASA Ames' Human Factors Research and Technology Division conducted intensive workshops for VA patient safety managers and officers who operate local patient safety efforts at VA facilities across the country. Based on feedback received at the workshops, PSRS developed multimedia educational products and focused outreach materials. In April 2002, NASA and the VA launched a national roll-out of the new PSRS.

After the national rollout, reports were received immediately. Presently, PSRS receives and analyzes data, conducts outreach briefings at VA facilities nationwide, and produces quarterly safety newsletters. PSRS also identifies ongoing safety hazards based on PSRS reports and distributes this information throughout the VA. As this effort continues to evolve, development of information technology tools will maximize analysis of PSRS reports for ease of database retrieval and the discovery of patterns. The innovations used in the development of the Patient Safety Reporting System should provide a proof-of-concept for confidential healthcare reporting systems nationwide.