December 13, 2022By Lance Baily

MUST DO: Contact Your U.S. House Rep to Support New Bill to Establish National Patient Safety Board

Industry changing news has been reported that impacts the field of healthcare simulation and future patient safety initiatives. According to the National Patient Safety Board (NPSB), U.S. Representative Nanette Barragán (D-CA) announced the introduction of H.R.9377 – the National Patient Safety Board Act in December 2022. This legislation is meant to establish an independent federal agency dedicated to preventing and reducing healthcare-related harms. This article explains how this landmark legislation is a critical step to improving safety for patients and healthcare providers. is a supporter of this initiative and asks that all U.S.-based healthcare simulation community members join in support by completing this short online form to contact your Congressional Representative!

The NPSB explained that, prior to the COVID-19 pandemic, medical error was the third leading cause of death in the United States. A conservative estimate accounts for more than 250,000 patients dying annually from preventable medical harm. The Patient Safety Network reports that these alarming statistics cost more than $17 billion to the U.S. healthcare system. For this reason, finding new ways to improve patient safety has remained paramount, and can undoubtedly be achieved through increased education and training efforts across medicine.

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Ultimately, this bill will improve upon existing coordination efforts within a single independent agency solely focused on addressing safety in health care through data-driven solutions. The National Patient Safety Board Act would establish a National Patient Safety Board (NPSB), “a nonpunitive, collaborative, independent agency modeled in part after the National Transportation Safety Board (NTSB) and the Commercial Aviation Safety Team (CAST) to address safety in health care.”

“We have seen many valiant efforts to reduce the problem of preventable medical error, but most of these have relied on the frontline workforce to do the work or take extraordinary precautions,” said Karen Wolk Feinstein, Ph.D., president, and CEO of the Pittsburgh Regional Health Initiative and spokesperson for the NPSB Advocacy Coalition. “The pandemic has now made things worse as weary, frustrated, and stressed nurses, doctors, and technicians leave clinical care, resulting in a cycle where harm becomes more prevalent. Many organizations have united to advance a national home for patient safety to promote substantive solutions, including those that deploy modern technologies to make safety as autonomous as possible.”

Designed to augment the work of federal agencies and long-standing patient safety organizations without displacing them, the NPSB envisions a public–private partnership team, the Healthcare Safety Team. This team would be tasked with gaining consensus on patient safety measures, autonomous data collection technologies, and solutions.

“Health care is moving to new venues, and the integration of technology is creating an army of new providers. Now more than ever, we need a national organization that looks broadly across the healthcare space and identifies ways that we can share experiences and insights that will make our systems of care safer for patients,” said Joanne M. Conroy, MD, chief executive officer and president of Dartmouth Health.

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Further, the NPSB reports that solutions would focus on problems like medication errors, wrong-site surgeries, hospital-acquired infections, errors in pathology labs, and issues in the transition from acute to long-term care. Plus, the NPSB’s solutions would help relieve the burden of data collection at the frontline, while also detecting precursors to harm. This would be achieved by leveraging interdisciplinary teams of researchers and new technology, including automated systems with AI algorithms.

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This bill follows in the footsteps of the aviation industry, which has had a stellar safety record. This can be attributed to the work of the NTSB and CAST, “which together have been improving and promoting transportation safety in the United States for more than 25 years.” The NPSB shares that this bill would similarly help guarantee a data-driven, scalable approach to preventing and reducing patient safety events in healthcare settings.

“As healthcare providers, our top priority and collective responsibility are to ensure the safety and well-being of our patients through highly reliable care that minimizes preventable harm. The establishment of a National Patient Safety Board would enable a collaborative, evidence-based, and scalable solution to optimize patient safety across our country’s healthcare system,” said Peter WT Pisters, MD, president of The University of Texas MD Anderson Cancer Center. Patient Safety Webinars:

In a press release sharing the establishment of H.R.9377, Carole Hemmelgarn, MS, MS, founding member of Patients for Patient Safety US shared that she is a mother who lost her child due to medical errors. From this experience, she wants to make sure there is learning from the events of her life so that medical error does not result in any additional deaths. She stressed that the United States needs a central agency like the National Patient Safety Board to gather data on these events, analyze them, share them, and develop solutions to mitigate them in the future. Continued Support

Prior to this announcement, published the article “Should the Healthcare Simulation Industry Join Calls for a National Patient Safety Board?” In this article, the question was posed: “Is it time the healthcare simulation industry called for a National Patient Safety Board?” During a Champions of Simulation 1-Day Virtual Symposium panel discussion in early 2022, expert panelists Dr. Paul Phrampus, Dr. KT Waxman, and Dr. Pam Boyers attempted to provide an answer. The presentation provided 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. They also reflected on the impacts of COVID-19 and debated the need to encourage healthcare simulation champions to support a new NPSB.

More About the National Patient Safety Board

A coalition of leading healthcare organizations and experts is advancing the call to expeditiously form a new independent federal agency, the National Patient Safety Board (NPSB), to model aspects of the National Transportation Safety Board and the Commercial Aviation Safety Team within healthcare. The NPSB would improve and promote public health and welfare by monitoring and anticipating adverse events, creating recommendations and solutions to prevent medical errors, and bringing lessons into practice.

Learn More & Support the National Patient Safety Board Act of 2022

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