Now is not soon enough: Patients, families and the general public have much to gain from the US National Patient Safety Board Act

Summary

In this blog, Olivia Lounsbury, Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee, looks at a new Bill calling for the creation of a US National Patient Safety Board (NPSB). She outlines why the NPSB is needed and demonstrates the importance of engaging patients and families in its design and processes. Olivia also look at existing healthcare safety organisations in other countries, highlighting the opportunity that the NSPB has to benefit from their approaches.

Content

When preventable harm in healthcare occurs, it is not uncommon for patients and family members to feel as though they are alone with nowhere to turn to report, reconcile or recover from the error. Doors close, eyes avert and they are left to pick up the pieces, with the fear that the same error will harm another patient in the near future. That’s exactly what happens to 250,000 Americans each year in US hospitals and healthcare organisations.[1] Unfortunately, despite best efforts, this problem continues to cripple patients, families and caregivers.  

Current experience of patients after medical error

Up until now, if patients experienced a medical error, their options to report it to bodies that could investigate the error and put solutions in place for the future were limited, if they existed at all. Though there have been strides to improve patient safety in the last several decades, medical errors are still too common, patients are still too often excluded from improvement discussions, and errors are reported in siloes across the country. 

Efforts to make significant advancements for patient safety

Given the significant patient safety challenges in the US, a number of healthcare organisations and expert representatives began to call for the creation of the US National Patient Safety Board (NPSB). The US’s NPSB would:

• monitor and anticipate patient safety events using artificial intelligence
• conduct multidisciplinary reviews to understand the causes of errors
• collaborate with existing systems to implement recommendations for improvement. 

The NPSB would ensure a scalable, data-driven and proactive approach to reducing preventable harm in healthcare. The NPSB concept is backed by a long history of attempts to establish a similar system. It now offers a solution to respond to these calls to action and synthesise existing efforts into a national oversight body. Patient and family member involvement will serve as a foundation for NPSB work, to ensure that recommendations from safety investigations are impactful and resonate with the needs of patients and families around the US.

Models from other countries

Other countries have experienced similar problems and have proposed the creation of their own national patient safety investigation bodies. Since implementation, these bodies, among others, have responded to healthcare safety concerns from patients, family members, members of the general public and healthcare staff by conducting formal investigations, proposing recommendations for improvement based on multidisciplinary discussion and widely reporting results for shared learning. These bodies also function as a mechanism to aggregate national patient safety concerns to better detect key themes in previously disparate areas. 

England’s Healthcare Safety Investigation Branch (HSIB) England established the Healthcare Safety Investigation Branch to improve patient safety through investigations for shared learning and improvement that avoid blame and liability. The HSIB philosophy clearly highlights the importance of patient and family engagement in their work. Recognising the differing needs in diverse patient populations, HSIB involves patients and family members in various ways in their national investigations and maternity investigations. Ensuring patients and family members are central to the investigation and proactively providing support are key principles embedded in each HSIB investigation. 

Norwegian Healthcare Investigation Board (NHIB) Norway has established a similar independent government agency called The Norwegian Healthcare Investigation Board to investigate adverse events and other serious concerns involving Norwegian healthcare services. NHIB involves patients and family members as partners in the dialogue throughout their investigations, with the aim of shedding light on gaps and hearing potential recommendations from their perspectives. 

Safety Investigation Authority, Finland (SIAF) Finland’s Safety Investigation Authority examines safety-related accidents across multiple sectors, including aviation, railroad, marine and health and social care. SIAF launches investigations into both individual accidents, as well as safety themes across the nation.

Given the transformative impact these bodies have had on improving safety, members of the NPSB coalition have made an effort to identify and include best practices from these organisations.

How will patients and family members be involved in the NPSB?

The organisations mentioned above have made strides in meaningfully including patients and family members in their investigations. Similarly, the NPSB has embedded stipulations for patient and family involvement into the fabric of the Bill. Specifically, the NPSB will involve patient representatives at the highest levels and ensure patients and family members have a readily-accessible portal to submit patient safety concerns. 

Why is the NPSB pivotal for patients, family members and members of the general public?

Patients, family members and the general public have the most to gain from a NPSB. 

• Firstly, not only will the NPSB act as an independent federal agency, but NPSB representatives will complement existing federal agencies to minimise duplicative work and amplify progress toward actionable solutions. 
• Secondly, the NPSB will offer patients and family members not only a place to report harm in healthcare, but also a seat at the table where the investigations are conducted and solutions are recommended. 
• Finally, the NPSB will accelerate the proactive identification of early indicators of patient safety problems around the nation through the use of robust data collection and artificial intelligence. 

Though some patient and family member representatives advocate for increased transparency and patient and family input in the current text of the Bill, the NPSB is an important first step in achieving safer healthcare and should continue to develop in these areas once established in the future. 

What will happen next with the NPSB? 

The H.R.9377 National Patient Safety Board Act was introduced on 1 December 1 2022 by US Representative Nanette Barragán (D-CA) and is expected to be reintroduced this year in the new Congress, where it will go through Committees in each chamber of Congress for members to research, discuss and potentially make changes. Once both the US House of Representatives and Senate have voted to accept the Bill, any differences will be reconciled and both will vote again. If the Bill passes both Chambers, it will go to the President to sign into law or veto.

What can I do to support the NPSB? 

The NPSB will revolutionise patient involvement in patient safety across the nation. Patients, family members and members of the general public are urged to find out more about the National Patient Safety Board or get involved in supporting the National Patient Safety Board Act by visiting the NPSB website or following NPSB on Facebook or Twitter. 

Related reading

Patient Safety Spotlight interview with Soojin Jun, Co-founder of Patients for Patient Safety US

How would a National Patient Safety Board (NPSB) benefit patients and families? (February 2023)

References

1 Study suggests medical errors now third leading cause of death in the U.S., John Hopkins Medicine, 3 May 2016

About the Author

Olivia Lounsbury is currently working in the Quality and Safety Department at Johns Hopkins Children's Center in the US and in the Department of Surgical Sciences at the University of Oxford in the UK. Outside of her full-time roles, she also serves as Editorial Assistant for the Journal of Patient Safety and Risk Management and Committee Lead for Patients for Patient Safety US's National Patient Safety Oversight committee. She graduated from Georgetown University with her master’s in Clinical Quality, Safety and Leadership with an emphasis on Human Factors.