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Efforts to form a national patient safety board would shape how medical errors and other patient harms are handled within the nation’s hospitals.
A coalition made up of stakeholders ranging from Dartmouth-Hitchcock and the Carlion Clinic to the Purchaser Business Group on Health and the National Quality Forum is pitching Congress on a government agency that would operate similarly to the National Transportation Safety Board, but for health providers. The new entity would focus on solutions to health safety problems and preventing deaths and other harm to patients.
“There’s a lot of good work out there that hasn’t been implemented on a national scale,” said coalition spokesperson Karen Wolk Feinstein, president & CEO of the Pittsburgh Regional Health Initiative and the Jewish Healthcare Foundation. “The purpose wouldn’t be to expose, penalize or call out providers, it’d be to simply look for solutions and long-term ways of avoiding harm.”
A patient safety board would analyze national data to see what kind of harm is occurring, and drill down to find out the similarities. It would then study potential solutions, and eventually make recommendations to industry.
Though there’s a plethora of data on how hospitals are faring, that knowledge doesn’t necessarily translate into change.
Safety isn’t a top priority for many hospitals nationwide, said Barbara Fain, the executive director of the Betsy Lehman Center for Patient Safety.
“It’s on the list somewhere, but when you look at where investment is actually happening, safety is kind of regarded as a siloed activity that the safety department does but it’s not integrated with in a way it needs to with the daily work of institutions,” said Fain, who is also heading up a multi-stakeholder strategic plan to improve patient safety in Massachusetts.
That’s in part because basic healthcare safety science is still a niche area that isn’t taught in medical school or in healthcare business administration programs for the most part. These events can include giving a patient the wrong dose of a medication, performing a procedure on the wrong patient, failing to follow-up on important lab results and spreading infections because of poor hygiene.
“Most CEOs of larger healthcare organizations don’t come to their jobs with that sort of training, so they’re lacking an understanding,” Fain said. “When their director of safety is saying, ‘we need to do these things,’ they may be thinking of it in terms of money, and not understand how it’s going to have impact.”
There are organizations, of course, that address aspects of safety. For instance, hospitals that are accredited by The Joint Commission are expected to report sentinel events that result in patient death or severe harm.
“But the definition of sentinel events are not fully understood and it’s not defined the same way in the mind of every healthcare provider,” said Stephen Grossbart, senior vice president and president of clinical quality analytics at Health Catalyst, and the former chief quality officer at Ohio-based system Mercy Health. “If there was a single clearinghouse, and if it was operating at the level of a national authority, I think that would catch healthcare’s attention more aggressively than the current processes we have.”
There are also not-for-profit organizations that alert hospitals when there are issues with certain provider-administered medications or supplies within a facility. But a governmental agency would carry more authority and perhaps make a bigger difference in hospital practices.
Concentrated potassium was a problem back in 2006 and caused a number of deaths around the country, said David Mayer, the executive director at the MedStar Institute for Quality and Safety Quality.
“And, and there’s very little reason to actually have concentrated potassium except in a couple of very limited instances, so the Institute for Safe Medication Practices made a recommendation to remove concentrated potassium from hospitals, except in these very specific circumstances; it was hard to get organizations around the country to buy into that,” Mayer said. “And [a national patient safety board] could make that kind of that kind of recommendation with more weight.”
Gary Kaplan, the outgoing longtime CEO of Virginia Mason Franciscan Health, said he hopes the potential board would be a vehicle for leveraging understanding of what happens when errors occur, and also to push change forward.
“I think there will be some pushback, but I would challenge all of us leading in healthcare to look at how we can change this paradigm and how we can embrace transparency to improve because without it, we’ll continue to have a fragmented piecemeal improvements,” Kaplan said.
The coalition currently has support on the republican side of Congress, and is looking for Democrats to co-sponsor potential legislation.
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