Peer Review of a Report on Strategies to
Improve Patient Safety
Paul C. Tang and Megan Kearney, Editors
Committee for a Peer Review of a Report on Strategies to Improve Patient Safety
Board on Health Care Services
Health and Medicine Division
A Consensus Study Report of
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This activity was supported by contracts between the National Academy of Sciences and the Agency for Healthcare Research and Quality. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Peer review of a report on strategies to improve patient safety. Washington, DC: The National Academies Press. https://doi.org/10.17226/26136.
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COMMITTEE FOR A PEER REVIEW OF A REPORT ON STRATEGIES TO IMPROVE PATIENT SAFETY
PAUL C. TANG (Chair), Adjunct Professor, Clinical Excellence Research Center, Department of Medicine, Stanford University School of Medicine; Physician, Palo Alto Medical Foundation
LEORA I. HORWITZ, Associate Professor, Department of Population Health and Department of Medicine, New York University Grossman School of Medicine; Director, Center for Healthcare Innovation and Delivery Science, NYU Langone Health
RAINU KAUSHAL, Senior Associate Dean for Clinical Research; Nanette Laitman Distinguished Professor and Chair, Department of Population Health Sciences, Weill Cornell Medicine; Physician-in-Chief of Population Health Sciences, NewYork-Presbyterian/Weill Cornell Medical Center
SANJAY SAINT, Chief of Medicine; Director, Veterans Affairs/University of Michigan Patient Safety Enhancement Program, VA Ann Arbor Healthcare System; George Dock Professor of Internal Medicine, University of Michigan
Study Staff
MEGAN KEARNEY, Study Director
KAREN HELSING, Senior Program Officer
TORRIE BROWN, Senior Program Assistant
SHARYL J. NASS, Senior Director, Board on Health Care Services
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Reviewers
This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report:
DAVID W. BATES, Brigham and Women’s Hospital
TEJAL K. GANDHI, Press Ganey Associates LLC
CHRISTOPHER P. LANDRIGAN, Harvard Medical School
ELIZABETH A. MCGLYNN, Kaiser Permanente Research
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by ALFRED O. BERG, University of Washington School of Medicine. He was responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.
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Acronyms and Abbreviations
AE | adverse event |
AHRQ | Agency for Healthcare Research and Quality |
ASRS | Aviation Safety Reporting System |
CAUTI | catheter-associated urinary tract infection |
CDC | Centers for Disease Control and Prevention |
CLABSI | central line–associated bloodstream infections |
CUSP | Comprehensive Unit-Based Safety Program |
EHR | electronic health record |
FAERS | FDA Adverse Event Reporting System |
FDA | U.S. Food and Drug Administration |
GTT | Global Trigger Tool |
HHS | U.S. Department of Health and Human Services |
HIT | health information technology |
ICU | intensive care unit |
IHI | Institute for Healthcare Improvement |
IT | information technology |
MHS | Making Healthcare Safer |
NCPS | National Center for Patient Safety |
NPSD | Network of Patient Safety Databases |
NPSIRS | National Patient Safety Incidents Reporting System |
NSQIP | National Surgical Quality Improvement Program |
OIG | Office of Inspector General |
PSI | patient safety indicator |
PSO | patient safety organization |
PSQIA | Patient Safety and Quality Improvement Act of 2005 |
PSR | patient safety report |
PSWP | patient safety work product |
VA | U.S. Department of Veterans Affairs |
VAERS | Vaccine Adverse Event Reporting System |
VAMC | VA Medical Centers |
VASQIP | VA Surgical Quality Improvement Program |
VHA | Veterans Health Administration |
Preface
Fifteen years ago, Congress passed the Patient Safety and Quality Improvement Act of 2005 (PSQIA), which established patient safety organizations (PSOs) and a Network of Patient Safety Databases (NPSD). The PSQIA made possible—in a legally protected and confidential manner—the collection, analysis, and use of aggregate data from multiple organizations to discover common themes in patient safety. These learnings could be used to forge systematic changes that substantially improve health care quality and safety across America. In short, the PSQIA could be the impetus to creating a nationwide learning health system. Through its enabling provisions, the PSQIA created a historic opportunity to place patient safety at the heart of health care delivery, just as the airline industry did with aviation safety.
The PSQIA required the Agency for Healthcare Research and Quality (AHRQ) to produce a report about effective strategies for reducing medical errors and increasing patient safety within 18 months of the NPSD becoming operational and to submit the draft report to the Institute of Medicine (IOM) (now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) for review. The peer-review committee closely examined the enabling PSQIA in detail and found the congressional intent clear: the purpose of creating the NPSD and PSOs that collect primary data was to “analyze national and regional statistics, including trends and patterns of health-care errors”1 to improve patient safety systematically. Consequently, the committee’s review accorded special attention to incentives and barriers to using the PSQIA-created resources—PSOs and the NPSD—to facilitate learning from aggregate data analysis.
The committee believes the country is at a relative standstill in patient safety progress. Although the original To Err Is Human report (IOM, 2000) commanded national attention more than two decades ago, the country has not achieved the level of safety in daily patient care that we have come to expect from other industries, such as when we board an airplane. Continuing on the current trajectory is not likely to produce substantial improvements in patient safety. The opportunity to demonstrably improve patient safety has never been greater as clinical data are now captured routinely in electronic health records (which was not the case in 2005), and the ability to transform those data for analysis at the population level continues to grow. Analyzing individual and aggregated population-level data makes it possible to learn what works and in what contexts. As an example, the potential to leverage PSOs to improve patient safety was highlighted in the IOM report Health IT and Patient Safety: Building Safer Systems for Better Care (IOM, 2012). In that report, the IOM identified a major barrier to preventing patient harm: the lack of aggregated patient-safety data related to health information technology (HIT). The
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1 PSQIA 2005 42 U.S.C. § 299b-22(j).
report recommended that PSOs be used to collect patient-safety incidents related to HIT across organizations nationally.
We look forward to the final AHRQ report enumerating current barriers to the efforts of PSOs and the NPSD to improve patient safety along with proposed strategies for overcoming them. We hope that executing those strategies will capitalize on the opportunity to create an upward trajectory in the nation’s ability to deliver safer care. With the proper focus, the nation could substantially improve the safety of Americans.
I thank my fellow committee members for their service and commitment to submitting a comprehensive review of AHRQ’s draft report, especially on an accelerated timeline.
Paul C. Tang, Chair
Committee for a Peer Review of a Report on Strategies to Improve Patient Safety