March 8, 2022By Lance Baily

Should the Healthcare Simulation Industry Join Calls for a National Patient Safety Board?

A new coalition has formed with the primary mission to create of a National Patient Safety Board (NPSB) in the United States, and so we must ask “Is it time the healthcare simulation industry called for a National Patient Safety Board?” That is the question clinical simulation expert panelists Dr. Paul Phrampus, Dr. KT Waxman, and Dr. Pam Boyers will attempt to address during a panel discussion at HealthySimulation.com‘s upcoming Champions of Simulation 1-Day Virtual Symposium this April 13th, alongside a plethora of other CE presentations (CME’s in application) specific to clinical simulation and patient safety. This article considers what a National Patient Safety Board would look like and covers the new coalition which is quickly gathering national support!

Introducing the NPSB Coalition

Formed just recently last year in 2021, the National Patient Safety Board Coalition is managed by staff of the Pittsburgh Regional Health Initiative, a division of the Jewish Healthcare Foundation which is lead by President and CEO Dr. Karen Wolk Feinstein. Dr. Feinstein will also be joining the panel discussion  at the upcoming Champions of Simulation virtual event hosted by HealthySimulation.com. The organization’s website NPSB.org notes that “previous efforts to improve healthcare patient safety processes and change behavior at healthcare’s frontline have been decentralized and have not been successful”, because they did not did not recommend “one federal agency to independently determine why the adverse events are occurring and create solutions to prevent recurrence”.


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The coalition suggests that the new NPSB be somewhat modeled off of the aviation industry’s National Transportation Safety Board (NTSB), which has a mission to make “transportation safer by conducting independent accident investigations, advocating for safety improvements, and deciding pilots’ and mariners’ certification appeals”; albeit with a data-driven, non-punitive, collaborative approach with a primary focus in three key areas:

  1. Identify and anticipate harm
  2. Conduct studies
  3. Create recommendations, including fail-safe solutions

Important to note is that this coalition suggests that the NPSB “will not directly collect data from providers” and that “studies and findings cannot be used in litigation. Certainly medical simulation can speak to each one of those agency focuses, providing ways to simulate clinical processes, support research studies, and to create fail-safe solutions. In fact, at the Virtual Symposium April 13th, Dr. AnneMarie Monachino will be presenting on “How to Use Medical Simulation to Intentionally Probe Healthcare Systems” which is a perfect example of how simulation can improve patient safety outcomes across an entire healthcare institution.

Ultimately, the NPSB, like the NTSB, would guarantee a data-driven, non-punitive, collaborative approach to reducing adverse events. The NPSB would exist as an independent agency created by Congress at the federal level and would interface with HHS agencies and offices (e.g. CMS, ONC, AHRQ, CDC, HRSA, SAMHSA, FDA, and NIH) and the VA, similar to how the NTSB interfaces with the Department of Transportation (DOT) and it’s Federal Aviation Administration (FAA). At its core, the NPSB would:

  • Support agencies in monitoring and anticipating adverse events with AI and machine learning technology
    Identify significant harm and then conduct studies of the adverse events
  • Create recommendations, including autonomous solutions, to prevent medical errors
  • The NPSB would send their recommendations and solutions to agencies and the industry based on the root causes of the adverse events that the NPSB studies. HHS would use its complementary functions (examples listed below) to act on the recommendations, sending a response to the NPSB within 90 days, similar to how the NPSB interfaces with the DOT.

To help alleviate these challenges and build on developments, such as the AHRQ Quality and Safety Review System (QSRS), the NPSB would help agencies select autonomous data collection systems to reduce duplication and inconsistencies, provide clinicians with a seamless flow of reliable information, and display real-time information via visual dashboards or Command and Control Centers.


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Upcoming NPSB Presentation/Breakout Sessions at HealthySimulation.com’s Champions of Simulation Virtual Symposium April 13th

To further advance the conversation of healthcare simulation, HealthySimulation.com is thrilled to announce the “Champions of Simulation” Virtual Symposium on April 13th, from ~8 AM to 4 PM PDT, UTC-7. This exciting virtual event will include over 18 sessions with presentations from more than 20 industry experts. One of these presenters will be Karen Feinstein, Ph.D., MSW, of the National Patient Safety Board Coalition:

(12:15 PM) General Session Discussion Panel: “Is It Time for the Healthcare Simulation Industry to Call for a National Patient Safety Board?” Panel members, Paul Phrampus, MD, FSSH, FACEP, KT Waxman, DNP, MBDA, RN, CNL, CHSE, CENP, FAONL, FSSH, FAAN, Pam Boyers, Ph.D., MA, and Karen Feinstein, Ph.D., will introduce the concept of a National Patient Safety Board, reflect on the impacts on COVID-19, and debate the need to encourage healthcare simulation champions to support a new NPSB.



(3:45 PM) Breakout Session F1: Non-Profits Supporting Patient Safety – Introduction 2: The National Patient Safety Board Advocacy Coalition: This presentation will provide an overview of the vision for a proposed NPSB and highlight how this agency would advance healthcare simulation technology in support of improving patient safety and reducing medical errors at a national scale.

Join live on the day to ask questions from some of the world’s leading experts, and/or rewatch any session as much as you like for 3 months following the event by registering now — but hurry — early-bird ends March 16th!


According to the NPSB’s “A New Solution to Address the Problem of Medical Errors” document, a defined, three-year period of developing and pilot testing the implementation and evaluation processes of the NPSB would occur before going live. During this period, the NPSB would inventory and select the adverse event indicators and the technologies to identify and anticipate the adverse events.

New Podcast: Up Next for Patient Safety By National Patient Safety Board Coalition: This podcast untangles the components of safer healthcare. Hosts engage in conversations with experts in healthcare and technology to examine the best paths to guarantee patient safety. Hear about different solutions to existing problems that are possible right now. The goal is to address those current and ongoing errors and adverse events that cause unnecessary illness, death, and long-term disability.

Have a personal story about an experience with a medical error or patient safety concerns? The Coalition invites others to share their stories to help advocate for an independent, non-punitive National Patient Safety Board to study medical mishaps and recommend solutions to prevent harm from happening again. Each story can help the Coalition to advocate for change that can save lives.

Learn More About the NPSB Initiative & Join Them Today!


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