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National Patient Safety Board
Prior to the COVID-19 pandemic, preventable medical error caused an estimated 250,000 deaths a year in the U.S., ranking as the 3rd leading cause of death. Despite broad awareness of the problem since the 2000 publication of the Institute of Medicine report To Err Is Human, we have failed to make significant progress over the past 20 years.
We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have been focused on the actions of the frontline workforce. This reliance on individuals is part of why efforts to sustain, spread, or standardize progress have been unsuccessful. The healthcare workforce is in crisis, and healthcare safety is suffering. Meanwhile, other industries have seen dramatic improvements in safety. Transportation, for instance, benefits from having that single federal agency with a clear, defined, and focused mission.
In early 2021, a growing coalition of leading healthcare organizations and experts led by the Pittsburgh Regional Health Initiative began to advance and call for the creation of a National Patient Safety Board (NPSB) to model the transportation industry's efforts in safety and bring a data-driven, scalable approach to preventing and reducing harms in health care.
“Effectively addressing today’s patient safety challenges requires advanced analytics and evidence-based solutions that work across clinical settings. It’s not enough for individual teams to implement changes at the local level if we want to address preventable medical harm in the U.S. We need to first examine the complex factors that lead to safety issues and use applied science and human factors engineering to create proactive systems-based interventions to create sustainable improvements in patient safety. The NPSB will enable broader adoption of this approach to safety across health care and benefit all patients.”