Since early 2021 there has been a growing coalition of healthcare organisations and groups calling to create the National Patient Safety Board in the United States.[1] This is a proposed federal agency with the goal of preventing and reducing patient safety events in healthcare settings, modelled after the National Transportation Board and the Commercial Aviation Safety Team.[2]

Legislative proposal

Nanette Barragán, US representative for California’s 44th Congressional District, has announced the introduction of new legislation intended to establish a National Patient Safety Board as a non-punitive, collaborative, independent agency to address safety in healthcare.[3] Its proposed duties are:

• Supporting Federal departments and agencies in monitoring and anticipating patient safety events with patient safety data surveillance technologies.
• Providing expertise to study the context and causes of patient safety events and solutions.
• Formulating recommendations and solutions to prevent patient safety events from occurring.

In carrying out this role, the National Patient Safety Board would be required to submit annual reports to the United States Congress and would also be able to hold hearings, take testimony, receive evidence and issue reports as appropriate.

It’s proposed to comprise:

• Five Board members, each nominated by the President, by and with the advice and consent for the US Senate, for a term of 6 years.
• A Chair and Vice Chair, designated by the President from among the members of the Board to serve a term of 3 years.

It is also proposed that it establishes and maintains a public-private team, known as the Health Care Safety Team, to sit underneath this to review, update and prioritise patient safety event measures and data sources related to patient and provider safety in healthcare settings, including survey data, electronic health records data, claims data, health information exchange data and reports of patient safety events.[4]

National Patient Safety Board campaign

You can find out more details about the campaign to support the creation of a National Patient Safety Board, and if relevant how to contact your US House member’s office in regards to this, here.

References

1. National Patient Safety Board, About, Last Accessed 9 December 2022.
2. National Patient Safety Board, A New Solution to Address the Problem of Medical Errors, 26 July 2022.
3. Business Wire, House Bill Establishes Federal Agency Dedicated to Patient Safety, 8 December 2022.
4. H.R.9377 - 117th Congress (2021-2022): National Patient Safety Board Act of 2022, 1 December 2022.

A recent report from the Centers for Disease Control and Prevention (CDC) evaluating causes for maternal death indicated issues related to mental health, such as depression, anxiety, death by suicide, and substance use disorders (SUDs) as the most frequent underlying cause, followed by clinical conditions.

Quick Safety Issue 66

Patients who are seriously ill often turn to, or are inappropriately admitted to, already overburdened emergency departments (EDs) for care that may be better addressed by palliative care services.

Quick Safety Issue 65

The purpose of this Quick Safety is to provide guidance for managing and storing packaged sterile supplies within your facility with the goal to keep patients safe from infection and other potential harm from expired or compromised supplies and devices.

Quick Safety Issue 64

Surgical instruments and other critical devices – those that enter sterile tissues – are reprocessed and reused every day in hospitals, ambulatory surgery centers, and other health care facilities. For organizations performing reprocessing, ensuring that those instruments and devices are reusable – that they are in good condition, and can be cleaned and sterilized following validated manufacturer’s instructions – is critical to patient safety.

Quick Safety Issue 63

Health care providers reported an increase in intimate partner violence (IPV) during the COVID-19 pandemic. IPV survivors seek medical care in many health care settings, but survivors often don’t readily share their abuse experiences with providers unless specifically asked and if they are ready to accept help.

Quick Safety Issue 62

Today’s always-online health care environment requires an all-hands approach to cybersecurity: a data safety culture which permeates the entire organisation and its operations.

Quick Safety Issue 61

It’s estimated that one in every 100 hospitalized patients will be affected by non-ventilator hospital-acquired pneumonia (NVHAP). This issue of Quick Safety focuses on the call’s challenge to health care systems to implement and support NVHAP prevention, and to add NVHAP prevention measures to education for patients, health care professionals and students.

Quick Safety Issue 60

The COVID-19 pandemic has shed a light on the many gaps in health care that diverse populations have experienced for decades. As integral parts of their communities, hospitals and medical centers need to understand the diverse populations they serve, including minority groups and vulnerable populations.

Call to Action

Patients, patient advocates, caregivers, pharmacists, healthcare workers, policymakers and industry experts are invited to take the pledge to support the statements to address patient safety across the globe.

Patient advocates from throughout the Asia-Pacific region gathered under one umbrella on the 17 November 2021, to explore some of the nuances that must be addressed to ensure patient safety. These conversations culminated in five strategies which are aligned to WHO GPSAP 2021-2030 in Strategic Objective 4: Patient and Family Engagement, namely:

• Engage - Partner and engage patients, families and civil society organisations in co-development of policies, plans, strategies, programmes and guidelines to make health care safer.
• Learn - Learn from the experience of patients and families exposed to unsafe care to improve understanding of the nature of harm and foster the development of more effective solutions.
• Capacity Building - Build the capacity of patient advocates and champions in patient safety.
• Transparency - Establish the principle and practice of openness and transparency throughout health care, including through patient safety disclosure to patients (and families when permitted).
• Education & Empowerment - Provide information and education to patients and families for their involvement in self-care and empower them for shared decision-making in relation to patient safety.

#UniteForPatientSafety Campaign

You can also join the virtual course - Patient Safety: Understanding the Global Patient Safety Action Plan 2021-2030

Causes of burnout

Workplace systems cause burnout among health workers, not individuals. There are a range of societal, cultural, structural, and organizational factors that contribute to burnout among health workers. Some examples include: excessive workloads, administrative burdens, limited say in scheduling, and lack of organizational support.

Workforce shortages

Physician demand will continue to grow faster than supply, leading to a shortage of between 54,100 and 139,000 physicians by 2033. The most alarming gaps are expected in primary care and rural communities.

Differential impacts on health workers

Burnout, resource shortages, and high risk for severe COVID-19 infections have unevenly impacted women and health workers of color. This is due to pre-existing inequities around social determinants of health, exacerbated by the pandemic.

Health worker burnout harms all of us

If not addressed, the health worker burnout crisis will make it harder for patients to get care when they need it, cause health costs to rise, hinder our ability to prepare for the next public health emergency, and worsen health disparities.

• Establishes grants for training health profession students, residents, or health care professionals in evidence-informed strategies to reduce and prevent suicide, burnout, mental health conditions, and substance use disorders. The grants would also help improve healthcare professionals’ well-being and job satisfaction.
• Seeks to identify and disseminate evidence-informed best practices for reducing and preventing suicide and burnout among healthcare professionals, training health care professionals in appropriate strategies, and promoting their mental and behavioural health and job satisfaction.
• Establishes a national evidence-based education and awareness campaign targeting healthcare professionals to encourage them to seek support and treatment for mental and behavioral health concerns.
• Establishes grants for employee education, peer-support programming, and mental and behavioural health treatment; health care providers in current or former COVID-19 hotspots will be prioritsed.
• Establishes a comprehensive study on health care professional mental and behavioural health and burnout, including the impact of the COVID-19 pandemic on such professionals’ health.

Twenty-five per cent of Medicare patients experienced patient harm during their hospital stays in October 2018. Patient harm includes adverse events and temporary harm events.

Twelve per cent of patients experienced adverse events, which are events that led to longer hospital stays, permanent harm, life-saving intervention, or death. In addition to the patients who experienced adverse events, 13% of patients experienced temporary harm events, which required intervention but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Temporary harm events were sometimes serious and could have caused further harm if providers had not promptly treated patients.

• Categories of Harm Events. The most common type of harm event was related to medication (43%), such as patients experiencing delirium or other changes in mental status. The remaining events related to patient care (23%), such as pressure injuries; to procedures and surgeries (22%), such as intraoperative hypotension; and to infections (11%), such as hospital-acquired respiratory infections.
• Preventability of Harm Events. Physician-reviewers determined that 43% of harm events were preventable, with preventable events commonly linked to substandard or inadequate care provided to the patient. (The overall harm rate would be 13% if we were to include only events that our physician-reviewers determined were preventable.) Reviewers determined that 56% of harm events were not preventable and occurred even though providers followed proper procedures. Events were determined not preventable for several reasons, including that the patients were found to be highly susceptible to the events because of their poor health status.
• CMS's Lists of Hospital-Acquired Conditions. CMS's two policies on hospital-acquired conditions (HACs) create payment incentives for harm prevention by reducing payment for certain HACs. However, because the policies use narrowly scoped lists of HACs and employ specific criteria for counting harm events, they have limited effectiveness in broadly promoting patient safety. The lists did not cover most of the harm events that patients in our study experienced. Of the harm events we identified, only 5% were on CMS's HAC Reduction Program list and only 2% were on CMS's Deficit Reduction Act HAC list.
• Harm Events Resulting in Costs to Medicare. Nearly a quarter of Medicare patients who experienced harm events (23%), either preventable or nonpreventable, required treatment that led to additional Medicare costs. These events also potentially increased patient costs in the form of coinsurance and deductible payments. Costs were incurred during the sample hospital stay or for an additional hospital stay necessary to ameliorate the harm. Combined, we estimated the costs for all events to be in the hundreds of millions of dollars for October 2018.

• The role of nurses in improving the health of individuals, families, and communities by addressing social determinants of health and providing effective, efficient, equitable, and accessible care for all across the care continuum, as well as identifying the system facilitators and barriers to achieving this goal.
• The current and future deployment of all levels of nurses across the care continuum, including in collaborative practice models, to address the challenges of building a culture of health.
• System facilitators and barriers to achieving a workforce that is diverse, including gender, race, and ethnicity, across all levels of nursing education.
• The role of the nursing profession in assuring that the voice of individuals, families and communities are incorporated into design and operations of clinical and community health systems.
• The training and competency-development needed to prepare nurses, including advanced practice nurses, to work outside of acute care settings and to lead efforts to build a culture of health and health equity, and the extent to which current curriculum meets these needs.
• The ability of nurses to serve as change agents in creating systems that bridge the delivery of health care and social needs care in the community.
• The research needed to identify or develop effective nursing practices for eliminating gaps and disparities in health care.
• The importance of nurse well-being and resilience in ensuring the delivery of high quality care and improving community health.
• The role of nurses in response to emergencies that arise due to natural and man-made disasters and the impact on health equity.

1. Staffing shortages.
2. COVID-19 effects on healthcare workers’ mental health.
3. Bias and racism in addressing patient safety.
4. Vaccine coverage gaps and errors.
5. Cognitive biases and diagnostic error.
6. Nonventilator healthcare-associated pneumonia.
7. Human factors in operationalizing telehealth.
8. International supply chain disruptions.
9. Products subject to emergency use authorisation.
10. Telemetry monitoring.

According to WHO, global health workforce is conservatively estimated to be just a little over 59 million. Africa has an average of 1,640,000, which is the lowest when compared with other regions. The world has a shortage of more than 4 million doctors, nurses, midwives and others, and Africa has the highest number of shortages. The African continent needs about 139 percentage increase, yet the few ones we have are fast relocating for better paying jobs in UK, UAE, Canada and America.

I took time to build this background so we can all understand the enormity of the concern.

For over one week now, most of the healthcare workers I know are hardly reachable through phone calls, I end up sending them WhatsApp messages and they respond to me they are now in the UK. Today was particularly bad for me when all messages i sent came with confirmation "I now work in UK". The few ones that have not left are waiting for one or two documents to aid their exit.

We have lost loads of Nigerian healthcare workers to the West and our government does not seem to care what will hit us in the future. I was told today that our Nurses in Government Hospitals leave in droves of sometimes 30 nurses at once. The time cometh when we will visit hospitals and not have healthcare workers to attend to us. This makes me sad!

Saudi Arabia came here to take our good hands under our nose, the government was quiet and perhaps even cheering the move. The Minister of Labour who is a doctor told us physicians can go into agriculture. Careless and senseless statements.

An average Nigerian nurse in the UK receives 60 - 80,000 GBP per annum. In Nigeria, an average monthly salary of a Senior Matron is barely N230,000.00.

In the future, it becomes unsafe to fall ill because the healthcare workers trained to look after you are all abroad at the service of foreign government and ailing African politicians and money bags!

When you do not value what you have, your neighbour will take it from you and place a premium on it.

Having a team of healthcare workers to attend to one patient in need of surgery like this will soon become luxury."

*This article was first published on LinkedIn.