Increasing adverse events, hospital-associated infections, and other harm to patients have compounded and now fuel the call for the formation of a national patient safety board. But, with so many established health entities already within the government, will adding one create more complexities than it will oversight?
A bill introduced in the House in December 2022 proposes such a body loosely modeled off the National Transportation Safety Board. The group behind the efforts for the board's creation note in a document that it still would not be the "sole solution" needed to properly address patient safety issues nationally, but rather is designed to "augment" the work of other federal agencies and patient safety organizations.
"The goal of the National Patient Safety Board is to prevent and reduce patient safety events in healthcare settings," the document reads. "As a non-punitive, collaborative, independent agency, the NPSB is modeled after the National Transportation Safety Board and the Commercial Aviation Safety Team. The NPSB, like the NTSB and CAST, would guarantee a data-driven, non-punitive, collaborative approach to preventing and reducing patient safety events in healthcare settings. Its goal is to dramatically improve the understanding of major sources of harm and bring stakeholders together to create solutions."
The bill proposes that it would not be necessary to identify providers in reports that the board would investigate, and some patient safety experts say this is not the right approach, noting that it would not provide the accountability necessary — particularly since the board would be nonpunitive to begin with. But others argue that this structure could help promote voluntary reporting for more data collection.
Three patient safety professionals shared their takes with Becker's.
Editor's note: Responses have been lightly edited for clarity and length.
Question: As a medical expert, how do you believe the establishment of a national patient safety board in the U.S. would impact the overall quality of healthcare?
Deborah Rhodes, MD. Enterprise Chief Quality Officer at Yale Medicine and Northeast Medical Group: Progress in healthcare quality and safety has not kept pace with other safety-focused industries, such as the aviation industry. Some of this has to do with the relative complexity of the underlying systems: Standard work is more feasible in the airline industry because airplanes are far less variable than patients! However, healthcare still has much to learn from advances in aviation safety: In the two decades since the publication of the IOM report, commercial aviation fatalities in the U.S. have decreased by 95 percent.
One key factor in this success is the National Transportation Safety Board, an independent federal agency. The Board does not have the authority to regulate, penalize or sanction, and yet has steadily and sustainably advanced aviation safety. There is now a growing coalition of healthcare and other organizations calling for the establishment of a National Patient Safety Board to play a similar role in healthcare.
Amrit Gil, MD. Associate Chief Safety Officer at Cleveland Clinic: Organizations such as the Agency for Healthcare Research and Quality as well as pediatric organizations like Solutions for Patient Safety have attempted to put a dollar amount on the cost of healthcare-acquired conditions (e.g., central line-associated blood stream infections, adverse drug events) that cause preventable harm. This cost when multiplied by the number of events happening in hospitals today is astronomical. Yet it pales in comparison to the impact of this harm on the real lives it affects: a life lost or significantly negatively impacted due to a preventable harm event in a setting where the expectation is healing; a family emotionally devastated and burdened with medical bills; the ripple effects on the second victims and the caregivers taking care of the patient that may have been involved in an error that caused harm to their patient.
We have a moral imperative to do better, and I believe the establishment of a national patient safety board or team will point us to our north star and provide an evidence-based structure where we can all learn and improve collectively to benefit our patients and our teams.
This body must demand rigorous attention to well-designed systems and processes as well as human-factor integration, health information technology, device safety, and safe transitions of care.
Jason Custer, MD. Director of Patient Safety at the University of Maryland Medical Center's downtown campus: What I feel are the barriers from the hospital side is that individual hospitals need to feel accountable to something for patients. Many of them are accountable to The Joint Commission. The Joint Commission does have a voluntary safety event set no event reporting tool. When you go down a legislative route, and create something like a National Patient Safety Board and you take that voluntary reporting route, the hesitancy from organizations is that they will be singled out. And alternatively, if you bring in external consultants, then they may not understand the clinical nuance of that case. So anytime that we review a case we want to make sure that we get sort of a comprehensive, multidisciplinary look.
I think hospitals would need assurances: one, that it would be anonymous and that these reports that were coming out of the board wouldn't carry a specific hospital label on it. Then two, to make sure that you have some of the team members that are closest to the case [involved]. You have to sort of listen to their perspectives and opinions of the nuances of that clinical care because with putting the patient at the center of it all, it is important to understand that all patients aren't the same.