The President's Council of Advisors on Science and Technology (PCAST) released its findings and recommendations on patient safety in a report to U.S. President Joe Biden. Titled "A Transformational Effort on Patient Safety," the report also outlines the many ways that "patient safety is an urgent national public health issue." The distinguished PCAST Working Group on Patient Safety is co-led by the founder of the Patient Safety Movement Foundation, Joe Kiani, and Microsoft's Chief Scientific Officer, Eric Horvitz.
The PCAST report to the Biden-Harris administration pointed out that according to recent data, "Medicare patients suffer an adverse event in one out of four hospitalizations, and one third of those adverse events are serious, including catastrophic outcomes," and that "adverse outcomes disproportionately impact people from groups historically experiencing social marginalization, widening gaps in healthcare disparities."
"Preventable medical errors take hundreds of thousands of lives each year. I am optimistic that these recommendations will help fast-track solving this critical problem that destroys so many lives," said Joe Kiani, co-leader of the PCAST Working Group on Patient Safety. "It was an honor to work with such a distinguished cohort of fellow PCAST committee members on what we believe is an urgent mission, and I am grateful for everyone's contributions. I know President Biden has been waiting for this report. He is our country's biggest patient advocate and cares deeply about the very real suffering that happens every day across the U.S. healthcare systems due to medical errors."
"This is a major milestone in healthcare safety in the United States, and if implemented, we believe it will influence and improve patient safety and healthcare worker safety around the world. Since our inception, we understood that for long-lasting change to happen, it would require direction from the highest levels of government. These recommendations could not have come at a better time because WHO's World Patient Safety Day is on September 17th," said Dr. Michael Ramsay, CEO of the Patient Safety Movement Foundation.
The report acknowledges that despite significant efforts made by many healthcare workers and organizations to reduce preventable medical errors by implementing evidence-based safety protocols, nationwide implementation of many of these known solutions has lagged. The report then outlines four recommendations to "advance health equity, improve the nation's health and well-being, and avert suffering and death for hundreds of thousands of Americans each year." The recommendations are as follows:
Recommendation 1: Establish and Maintain Federal Leadership for the Improvement of Patient Safety as a National Priority.
1.A Appoint a Patient Safety Coordinator Reporting to the President on Efforts to Transform Patient Safety Among All Relevant Government Agencies.
1.B Establish a Multidisciplinary National Patient Safety Team (NPST) and Ensure Inclusion of Persons from Populations Most Affected.
Recommendation 2: Ensure That Patients Receive Evidence-Based Practices for Preventing Harm and Addressing Risks.
2.A Identify and Address High-Priority Harms and Promote Patient Safety Though Incentivizing the Adoption of Evidence-Based Solutions and Requiring Annual Public Reporting Immediately and Quarterly Public Reporting Within 5 Years.
2.B Create a Learning Ecosystem and Shared Accountability System to Ensure That Evidence-Based Practices are Implemented and Goals for Reduced Harms and Risks of Harm for Every American are Realized.
2.C Advance Interoperability of Healthcare Data and Assure Access to the Tracking of Harms and Use of Evidence-Based Solutions.
2.D Improve Safety for All Healthcare Workers and Their Patients Through Supporting a Just Culture of Patient and Clinician Safety in Healthcare Systems.
Recommendation 3: Partner with Patients and Reduce Disparities in Medical Errors and Adverse Outcomes.
3.A Implement a "Whole of Society Approach" in the Transformational Effort on Patient Safety.
3.B Improve Data and Transparency to Reduce Disparities.
Recommendation 4: Accelerate Research and Deployment of Practices, Technologies, and Exemplar Systems of Safe Care.
4.A Develop a National Patient Safety Research Agenda.
4.B Harness Revolutionary Advances in Information Technologies.
4.C Develop Federal Healthcare Delivery Systems' Capacities and Showcase Results as Exemplars for Safer Healthcare.
PCAST is a federal advisory committee appointed by the U.S. president to augment the science and technology advice available to him. PCAST consists of 28 of the nation's thought leaders, selected for their distinguished service and accomplishments in academia, government, and the private sector. Joe Kiani, who founded the Patient Safety Movement Foundation (PSMF) in 2012 and served for many years as its first chair, was appointed to PCAST in September 2021. Also serving with Kiani and Horvitz in the PCAST patient safety working group are:
- Donald Berwick, MD, Patient safety expert, CMS, Institute for Healthcare Improvement
- Lisa Cooper, Johns Hopkins University
- Sue Desmond-Hellmann, Former CEO, Gates Foundation, Former Chancellor UCSF
- Christopher Hart, Safety systems expert, National Transportation Safety Board
- Harlan Krumholz, MD, Outcomes research pioneer, Yale University
- Julie Morath, RN, Patient safety expert, Hospital Quality Institute
- Peter Pronovost, MD, Patient safety expert, University Hospitals Cleveland Medical Center
- Sue Sheridan, Patient advocate, Patients for Patient Safety
ABOUT THE PATIENT SAFETY MOVEMENT FOUNDATION
In 2012, Joe Kiani founded the non-profit Patient Safety Movement Foundation (PSMF) to eliminate preventable medical errors in hospitals. His team worked with patient safety experts from around the world to create Actionable Evidence-Based Practices (AEBP) that address the top challenges. The AEBP are available without charge to hospitals online. Hospitals are encouraged to make a formal commitment to ZERO preventable deaths, and healthcare technology companies are asked to sign the Open Data Pledge to share their data so that predictive algorithms that can identify errors before they become fatal can be developed. The Foundation's annual World Patient Safety, Science Technology Summit brings together all stakeholders, including patients, healthcare providers, medical technology companies, government employers, and private payers. The PSMF was established through the support of the Masimo Foundation for Ethics, Innovation, and Competition in Healthcare. For more information, please visit psmf.org.
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Contacts:
Patient Safety Movement Foundation
Irene Mulonni, irene@mulonni.com (858) 859-7001
