PCAST Report to U.S. President Outlines “A Transformational Effort on Patient Safety”

The President’s Council of Advisors on Science and Technology (PCAST) has just released its findings and recommendations on patient safety in a report to U.S. President Joe Biden. Titled “A Transformational Effort on Patient Safety,” the report draws much-needed attention to the fact that patient safety is an urgent national public health issue. The report’s goal is to empower existing and new efforts that will transform patient safety. Participating in the preparation of the report was a PCAST Working Group on Patient Safety co-led by the founder of the Patient Safety Movement Foundation, Joe Kiani, and Microsoft’s Chief Scientific Officer, Eric Horvitz.

The report cites that according to recent data, approximately one in four Medicare patients experience adverse events during their hospitalizations, with many resulting in catastrophic outcomes, including death. More than 40 percent of these events are due to preventable errors.

Critically, the PCAST report to the White House administration acknowledges that “harm from unsafe care occurs in all healthcare settings and affects all persons, from mothers and babies to seniors,” and moreover, “adverse outcomes of unsafe care disproportionately impact people experiencing social marginalization due to race, ethnicity, sexual orientation, gender identity, income, education, socioeconomic status, or physical and mental ability, resulting in health disparities.” The report also lists examples of the most common medical harms, including medication errors, hospital-associated infections, surgical injuries, diagnostic errors and delays, medical device malfunctions, and “failure to rescue.”

As the report points out, medical errors and patient injuries persist at alarmingly high rates despite ongoing efforts to improve quality care on the part of practitioners and their organizations. Central to these efforts is the progress that has been made over the last two decades to understand the root causes of avoidable medical errors and to devise evidence-based solutions to reduce some of the most common forms of injury. In addition to evidence-based solutions for minimizing treatment-specific issues, like hospital-associated infections, pressure ulcers, medication errors, and surgical mishaps, safety protocols for “systems level” practices have also been developed. Most of these safety protocols are covered by the Actionable Evidence-Based Practices blueprints provided free of charge by the Patient Safety Movement Foundation.

The PCAST report reveals that despite these efforts by many healthcare workers and organizations to reduce preventable medical errors through implementing evidence-based safety protocols, nationwide implementation of many of these known solutions has lagged. It goes on to urge that now is the right time to renew the nation’s commitment to improving patient safety, stating that “parallel to improvement of patient safety is the additional and closely linked aim of improving safety for the healthcare workforce.”

Noting that changes will be far more likely with strong committed government leadership, the report outlines recommendations in four main areas. Together, the goal of these recommendations is to “(a) create a nationwide transformational initiative to support every hospital and practitioner in implementing known safety solutions for both patients and the workforce and sustaining them over time; and (b) create and maintain a robust national enterprise aimed at accelerating research, development, and deployment of technology and policies aimed at improving patient safety.”

The recommendations are as follows:

Recommendation 1: Establish and Maintain Federal Leadership for the Improvement of Patient Safety as a National Priority.

1.A Appoint a Patient Safety Coordinator Reporting to the President on Efforts to Transform Patient Safety Among All Relevant Government Agencies.

1.B Establish a Multidisciplinary National Patient Safety Team (NPST) and Ensure Inclusion of Persons from Populations Most Affected.

Recommendation 2: Ensure That Patients Receive Evidence-Based Practices for Preventing Harm and Addressing Risks.

2.A Identify and Address High-Priority Harms and Promote Patient Safety Though Incentivizing the Adoption of Evidence-Based Solutions and Requiring Annual Public Reporting Immediately and Quarterly Public Reporting Within 5 Years.

2.B Create a Learning Ecosystem and Shared Accountability System to Ensure That Evidence-Based Practices are Implemented and Goals for Reduced Harms and Risks of Harm for Every American are Realized.

2.C Advance Interoperability of Healthcare Data and Assure Access to the Tracking of Harms and Use of Evidence-Based Solutions.

2.D Improve Safety for All Healthcare Workers and Their Patients Through Supporting a Just Culture of Patient and Clinician Safety in Healthcare Systems.

Recommendation 3: Partner with Patients and Reduce Disparities in Medical Errors and Adverse Outcomes.

3.A Implement a “Whole of Society Approach” in the Transformational Effort on Patient Safety.

3.B Improve Data and Transparency to Reduce Disparities.

Recommendation 4: Accelerate Research and Deployment of Practices, Technologies, and Exemplar Systems of Safe Care.

4.A Develop a National Patient Safety Research Agenda.

4.B Harness Revolutionary Advances in Information Technologies.

4.C Develop Federal Healthcare Delivery Systems’ Capacities and Showcase Results as Exemplars for Safer Healthcare.




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