COVID-19 has exposed the urgent need for a National Patient Safety Authority

For this year’s World Patient Safety Day (Sept. 17), we must acknowledge what the pandemic has exposed: the U.S. fails in using its extraordinary technology and information system capabilities to keep its patients and healthcare workers safe. The current crisis only emphasizes what our annual death rate from preventable medical error—upwards of 250,000 people a year—reveals. We are not resilient, resourceful or prepared to protect patients or workers.

The problems could be addressed with a strong national agency that can, at once, overcome a lack of preparedness for a pandemic as well as reduce our annual death toll from medical errors. Such an agency or authority would deploy a centralized, intelligent engineering system to anticipate shortages of supplies, test kits, and medications; correct our inefficient distribution system; rapidly extract best practices from our electronic health records and share them with front-line clinicians; and create a national and global safety learning network. What could be accomplished autonomously and virtually through available technologies would be deployed.

Think of NASA and all that went into landing a man safely on the moon. And those lessons are from more than 50 years ago. NASA needed to anticipate every conceivable harm and disaster and create corrective autonomous prevention systems. Human and technical error are both minimized when technology is applied to every conceivable glitch before takeoff. A command and control center assembles all the necessary expertise and data to continuously monitor a journey for signs of dysfunction and remotely resolve as many errors as possible. Where human life is concerned, harm and failure aren’t acceptable. And after every major event, all major glitches or incidents are investigated intensely, solutions identified and not repeated. This is what fail-safe systems do routinely. This is what we don’t do so well in healthcare.

We’re safer when we travel on highways, on tracks, and in the air because the National Transportation Safety Board performs these same functions. Using available data, technology and expert incident investigators, the NTSB proposes policy solutions (e.g., school bus construction guidelines), behavior changes (e.g., smoke detectors) or autonomous systems (e.g., airbags). The Department of Transportation, the Federal Aviation Administration and other regulators have adopted 90% of these recommendations. James Fallow asks in the June 29 issue of the Atlantic, “Imagine if the National Transportation Safety Board investigated America’s response to the coronavirus pandemic?” I know what would happen. We’d create a National Patient Safety Authority.

Why not? Why not protect patients and healthcare workers with the same focus and innovation that we’ve used to mitigate the risks from transportation, nuclear power, bioterrorism and cyberattacks? Right now, in the U.S., we collect data on patient or worker safety from 15 federal agencies, 80 state patient-safety organizations and numerous independent agencies. But we lack a centralized entity to capture and align these data for rapid, reliable and seamless flows of information to our front lines of care. We have yet to fully take advantage our $30 billion investment in electronic health records to identify the anomalies that tell us about best and worst practices—in real time, and we do not apply our learnings widely to save lives.

By not relying on new technologies such as predictive analytics, machine learning, artificial intelligence, and robotics, we have failed to relieve our clinicians of more reporting, longer checklists and inadvertent harms.

If we ask, what can the U.S. do to create the same safety and risk-avoidance protections that we do for our astronauts, those who work or live in proximity to nuclear power plants, and all travelers and pilots, we make an obvious suggestion: Create a National Patient Safety Authority.


Tags: covid-19, pandemic

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