What Is the Proposed National Patient Safety Board, and How Can It Benefit Physicians?

KaRen WOlK Feinstein, PhD PResiDent anD CeO, jeWish healthCaRe FOunDatiOn anD PittsBuRGh ReGiOnal health initiative

For over 25 years, the Pittsburgh Regional Health Initiative (PRHI) has been seeking solutions to the problem of preventable medical harms and supporting the region’s leaders in advancing healthcare safety. PRHI has piloted initiatives that have demonstrated success in reducing harms, but sustained efforts have fallen short, leading to a shift in tactics: a new focus on policy change at the federal level and the Regional Autonomous Patient Safety (RAPS) initiative focused establishing the Pittsburgh region as a hub for healthcare technology innovation. Both come at a time when our healthcare systems and our providers have been contending with unprecedented strains and stresses.

The Burden on Providers

Much has been emerging regarding the increasing impact of the COVID-19 pandemic on patient safety. With a recent report by the Office of the Inspector General(1) and a New England Journal of Medicine study(2) both showing high rates of harm prior the pandemic, the recent outlook has unfortunately only gotten worse. A New England Journal of Medicine piece in February 2022(3) described “substantial deterioration” in patient safety measures during COVID-19, outlining how gains in prevention of healthcare-acquired infections realized prior to the start of the pandemic have vanished. Undoubtedly, the pandemic’s strain on the healthcare workforce has had a direct effect on the safety of patients and workers. Staffing shortages, burnout, supply chain issues, poorly implemented technology solutions, and other factors continue to overburden workers and have pushed many providers to leave the profession(4).

Physicians deserve a healthcare system that is better designed for patient care and optimizing safety. Performing workarounds because devices and systems do not integrate properly and are not user friendly has become commonplace, but this practice can also be a critical point for introduction of errors. Overly complex data collection and reporting add burdens on providers and often result in data “siloes” that are unable to communicate across systems, a fertile ground for errors that lead to harm. Our systems are simply not designed to support workers in providing safe, effective, efficient care.

Providers must not be asked to do more in this current climate. Instead, we need to employ autonomous solutions and use human factors engineering principles to build a better work environment with better equipment to achieve safe, optimal care. Such technologies and practices widely deployed in other industries have made incredible strides in safety. Even within medical specialties such as anesthesia, technology and human factors approaches have been embraced to mitigate the potential for harms. It’s time for the rest of health care to benefit from these advances that support providers in delivering the safest care possible.

A New Federal Solution

Over the past two years, the Pittsburgh Regional Health Initiative has helped to guide a coalition of leaders in health care, technology, business, academia, and other industries in a united push for federal action to address the deficiencies in our current systems. This past December, U.S. Representative Nanette Barragán (D-CA) responded by introducing H.R.9377 – the National Patient Safety Board (NPSB) Act of 2022(5), legislation to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms. This landmark legislation is a critical step to improve safety for patients and healthcare providers by coordinating existing efforts within a single agency solely focused on addressing safety in health care through data-driven solutions. Modeled in part after the highly successful National Transportation Safety Board and Commercial Aviation Safety Team, the NPSB will serve as a nonpunitive, collaborative, independent agency that will guarantee a data-driven, scalable approach to preventing and reducing patient safety events in healthcare settings and alleviate strain on providers.

Responsibility for aspects of patient safety is currently spread across an array of government agencies. The result is a fragmented, uncoordinated response and siloed data that hinder our ability to identify precursors to harm and prevent future harms. A key feature of the NPSB is an interdisciplinary, public–private Healthcare Safety Team, which would identify patterns and causes of errors that are happening in healthcare settings across the U.S., with the sole purpose to identify scalable solutions focused on addressing problems such as medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in transitions across care settings. By leveraging interdisciplinary teams of researchers and new technologies, including automated systems with AI algorithms(6) and the benefit of human factors engineering, the NPSB’s solutions would help to relieve the burden of data collection at the frontline; ensure that devices and equipment—including electronic health records—are engineered with compatibility and the end user in mind; and, perhaps most importantly, detect precursors to harm. Individual healthcare systems are already using advanced analytics and machine learning technologies to improve safety across their facilities, but these advances are not broadly shared. An NPSB will promote dissemination of patient safety solutions nationwide so that systems large and small can benefit from them.

Overrides and customizations to address safety issues that arise after a system is implemented cost time and money and compromise safety. Healthcare facilities and providers deserve to be confident that the equipment and systems they purchase have been thoroughly tested for safety and effectiveness. Given the persistent burden that staffing shortages are putting on our healthcare system and our providers, it is imperative that we take the burden off the frontline by focusing on autonomous solutions and building better systems using human-factors engineering.

How You Can Help

Provider support is key to the success of any patient safety improvement effort. The NPSB Advocacy Coalition invites you to learn more about how an NPSB can support physicians in providing safe, high-quality care while minimizing the burden on the front lines. Visit npsb.org for information and resources on how an NPSB can make health care safer, learn how your organization can join the Coalition, and contact your elected officials to express support for reintroduction of NPSB legislation in the current term. Let your colleagues know about this effort.

The RAPS initiative launched in February to bring together the local health systems, providers, tech innovators, and academics to work on establishing the Pittsburgh region as a hub for developing solutions that will ease the burden on providers. Learn more at https://bit.ly/3KI1vky

There will be future pandemics. There will be future workforce crises. We all need to amplify our request for progress and powerful solutions. We need the power of autonomous solutions to make health care safer. An NPSB is key to making any meaningful change. We invite you to support this critical effort.

References

(1) \Office of the Inspector General. (2022, May). Adverse events in hospitals: a quarter of Medicare patients experienced harm in October 2018. https://oig.hhs.gov/oei/ reports/OEI-06-18-00400.pdf

(2) Bates, D. W., et al. (2023). The safety of inpatient health care. N Engl J Med, 388(2):142-153. https://doi.org/10.1056/ NEJMsa2206117

(3) Fleischer, L. A., et al. (2022). Health care safety during the pandemic and beyond — Building a system that ensures resilience. N Engl J Med, 386:609-611. https://doi. org/10.1056/NEJMp2118285

(4) Hodkinson, A., et al.(2022). Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis. BMJ, 378:e070442. https://doi.org/10.1136/bmj2022-070442

(5) Congress.gov. “Text - H.R.9377 - 117th Congress (2021-2022): National Patient Safety Board Act of 2022.” December 1, 2022. https://www.congress.gov/ bill/117th-congress/house-bill/9377/text

(6) Classen, D. C., et al. (2023). Bending the patient safety curve: how much can AI help? npj Digit. Med. 6:2. https://doi. org/10.1038/s41746-022-00731-5

(7) Agency for Healthcare Research and Quality. (2019). Human factors engineering. https://psnet.ahrq.gov/primer/ human-factors-engineering